Integration Improves the Odds: Lessons Learned. Monday, December 18 th, 2017
|
|
- Randell Ronald Gray
- 5 years ago
- Views:
Transcription
1 Integration Improves the Odds: Lessons Learned Monday, December 18 th, 2017
2 Julie Cornell, North America Regional Manager, Global Community Impact
3 INTEGRATION IMPROVES THE ODDS Lessons Learned Webinar - National Council for Behavioral Health
4 PRESENTERS Sheila O Neill, LCSW and Kristin Davis, Ph.D.
5 Thresholds has more than 55 years of experience in evidence-based community mental health services. We improve health outcomes and save money. Thresholds programs are located in the city of Chicago and five surrounding counties in northern IL. Thresholds has challenged and changed psychiatric rehabilitation practices, believing and demonstrating that with the proper supports and treatment, persons with mental illness can begin a recovery that will lead to a more fulfilling life. The agency is an internationally-recognized model of mental health care, and we are expanding our services to include more integrated healthcare.
6 THRESHOLDS SERVICES Thresholds provides the following behavioral health services: Assertive Community Treatment (ACT) Community Support Housing supports Follow up after Hospitalization (FUH HEDIS quality measure) Supported Education Supported Employment Integrated Healthcare Psychiatric Services Substance Use Treatment In addition, we have tailored programming for specific populations: Veterans Young Mothers Young Adults (16-21) Emerging Adults (18-28) Persons who are Homeless Deaf or Hard of Hearing Commercial Insurance and Private Payers
7 THRESHOLDS MEMBERS SERVED FY17 TOTAL MEMBERS SERVED: 17, % 50% 11,060 (64%) 6,225 (36%) CONTINUOUS CARE TEAM: 6, (10%) 2,306 (37%) 3,307 (53%) Touched 73 % CSI CST ACT
8 THRESHOLDS MEMBERS AT INTAKE: CHARACTERISTICS AXIS 1 DIAGNOSES CO-OCCURRING SUBSTANCE USE 100% 40% Schizoaffective Disorders 50% Bipolar or Major Depression 50% JUSTICE INVOLVED UNEMPLOYED HIGH SCHOOL EDUCATED 49% 90% 73 % *Avg. Income $9,869
9 Thresholds adds physical health and well-being as a goal area. Family Nurse Practitioners from University of IL College (UIC) of Nursing begin delivering primary care services to members of Thresholds South. Added psychiatry at a later date HISTORY OF INTEGRATED CARE AT THRESHOLDS 1998 Second UIC clinic opens at a Thresholds north side location Thresholds sought new FQHC partners Opened three Integrated Care Centers at Thresholds locations 2017
10 PATH TO INTEGRATED CARE Coordinated Co-location Integration
11 INTEGRATED CARE AT THRESHOLDS Delivery System Design ACT and other Thresholds Nursing Substance Use TX Community Support/ACT Team Member Integrated Health Care Pharmacy Physical Space EBPs Social Determinants
12 INTEGRATION ENGINE*: FACILITATING CARE COORDINATION AND QUALITY CARE *Johnson and Johnson Foundation Funded
13 Integration Engine A middleware application which transforms, routes, and translates messages Extracts vital data from two health records and allows it to be shared and/or placed in each others EHRs (read-only). Built specifically for health care industry and is used for exchange of health data. Connects legacy systems by using a standard messaging protocol.
14 INTEGRATION ENGINE All appointment data is shared with Thresholds upcoming appointments, type of appointment, etc. Rates of appointment engagement and follow up (able to break down by Thresholds program, team, type of service, PCP and psychiatry note (from partner to Thresholds EHR) DXs, medications, key health indicators (from partner to Thresholds EHR) Shared Outcomes and focus Blood pressure Diabetes control BMI Smoking
15 LESSONS LEARNED Compatible partner culture Shared vision and values Commitment of staff time and expertise Commitment to quality and patient outcomes Cross training for staff and co-interviewing new providers Leadership styles and structure Inter-professional communication and collaboration skills
16 LESSONS LEARNED Complex population and busy staff Staff education, training, comfort with SMI Sharing data/integrated Medical Record Billing/Reimbursement for services longer visits Financial investment and sustainability Overall system is not integrated (hospitals, specialty care)
17
18
19
20 Primary Care- Behavioral Health Integration Project Rina Ramirez, MD, Chief Medical Officer
21 Zufall Health Center A Federally Qualified Health Center since 2004 Established as the Dover Free Clinic in 1990 Zufall operates Eight offices in six counties Medical van Dental van Wellness Center NCQA Accredited Patient Centered Medical Home HRSA Designated National Quality Leader CDC Recognized Hypertension Champion Target BP Gold Level 21
22 Zufall Health 2017 Statistics (Projected) Served 37,000 patients in 125,000 visits 88% at or below 200% of Federal Poverty Level 50% of patients were uninsured 65% of patients were Latino 56% best served in a language other than English
23 Zufall Health Services Core Services Pediatrics, Adult Medicine, Women s Health, Dental, Behavioral Health, HIV Services, Podiatry, Neurology Supportive Programs 340B Contract Pharmacy, Clinical Pharmacy, Presumptive Eligibility/Enrollment, Case Management & Patient Navigation, Patient Portal Access Community Outreach and Service Programs - Health Education/Screenings, Enrollment Assistance, HIV Testing, Outreach and Programs for Special Populations, School-based dental screening and prophylaxis
24 Primary Care Integration in the Behavioral Health Setting the Need Enhance access to primary care services for vulnerable, underserved SMI patients by addressing barriers transportation, low income, fear, lack of social support, language barriers Manage chronic medical conditions; Increase needed follow up visits Provide comprehensive services Improve communication and coordinate care Improve clinical outcomes
25 Our Integration Philosophy Patient-centered, team-based, one-stop shop Trusted clinical staff; Familiar faces, places, processes Patient Navigator as link between primary and BH clinical services Case by case navigation Direct access to PC, multidisciplinary team Expedited access to clinician appointments Sharing of medical and psychiatric information (by informed consent) Communications between the clinical staff at both sites enhanced
26 First Phase: Collaboration with BH via Patient Navigator, no co-location Partnership with Saint Clare s Medical Center since 2009 the largest provider of BH services in region. Full-time patient navigator (Zufall staff member), located at St. Clare s BH offices Patient Navigator as link/liaison between primary and BH clinical services Patient navigator has access to both BH and medical records PN identifies patients needing services and assesses specific healthcare needs; addresses barriers to access; provide for PC registration and appointment making in the BH setting; assist with follow through, aftercare and linkage to specialty care
27 Key to Success Patient Navigator Nurture relationship with patient on behalf of the helping system Educate PC practice in the patient s perspective on care and how to address problems; educate patient on health and illness, educate BH staff on Zufall system Teach patients about social articulation how to be a successful patient Foster activation and health behavior change One to one hands-on case navigation
28 Second Phase: Co-location of services using Mobile Vans* Trial of co-location at separate BH site was unsuccessful Medical van to BH St Clare s outpatient campus Weekly all day sessions, same day of the week Same medical provider sensitive to needs of BH patients Bilingual support staff Physical Exams Acute illness care Continuity of care and follow up visits Preventive screenings Dental screenings/care Women s healthcare Patient Education On-site laboratory and point of care testing
29 Findings to date Increased access On site, no travel for patients Patient Navigator personal assistance Increase in visits and patients seen Increased demand for appointments Improvement in healthcare outcomes Increased patient and organizational satisfaction Access to multidisciplinary, team-based care Medical Dental Clinical Pharmacy Women s Health
30 BH Integration Statistics 2017 (Phases 1 and 2) Number of patients 790 Number of visits 3,600 Number of dental visits 1,100 Average number of PC visits/yr 4.5 (3.5 for all Zufall) No show rates 16.6% (17.2% for all Zufall) Percent overweight/obese 74% Percent with hypertension 31% Percent with DM - 17%
31 Top 5 Diagnoses- BH Integration Psychiatric Schizophrenia Schizoaffective Disorder Affective Disorders PTSD Alcohol/Drug Dependence Medical Overweight/Obese Hypertension Diabetes Tobacco Use Disorder COPD
32 Clinical Outcomes Tracking from 2013 on Hypertension Diabetes Cervical Cancer Screening Tracking in 2017 Breast Cancer Screening Colorectal Cancer Screening
33 90% Behavioral Health Integration Program Percent with BP in Control (<140/90) by Year All Zufall 2017 (75%) 80% 80% 70% 69% 67% 60% 61% 50% 48% 40% 30% 20% 10% 0%
34 90% Zufall Behavioral Health Integration Program Diabetes in Control/Uncontrolled by Year All Zufall Controlled 73% 80% 78% 74% 73% 77% 70% 66% 60% 50% 40% 34% Under 9 Over 9 30% 22% 26% 27% 23% 20% 10% 0%
35 100% Zufall Behavioral Health Integration Program Cervical Cancer Screening Rates by Year All Zufall Rates 83% 90% 80% 70% 70% 60% 50% 52% 60% 61% 61% 40% 30% 20% 10% 0%
36 New Clinical Measures Breast Cancer Screening BH Patients 51% Colon Cancer Screening BH Patients 59% All Zufall 55% All Zufall 62%
37 Lesson Learned - Financial Impact Improvement in clinical measures = potential performance bonuses Increase in visits = increase in fee for service revenue High risk pool = enhanced risk scoring with favorable revenue from ACO Access to Primary Care and Medications = reduced ED costs 340B Savings = increased revenue from insurances Inefficiencies in scheduling in mobile services = decreased productivity PN Services sustained by grant funding Management and oversight of program, QA processes not funded
38 Lessons Learned - Challenges PCP knowledge psychiatric conditions and medications Sharing of records, data and outcomes Adapting to different practice models Managing two different payment systems State regulations matter Size of partner organizations matter
39 Lessons Learned Personal attributes as important as processes Leadership support with devoted resources Time for trainings and meetings Infrastructure Performance Improvement team/processes
40 What s Next Use data to improve care, offer additional needed services, focus on areas that need attention Increase team interactions with scheduled meetings, updated procedures and protocols, case reviews Improve care coordination through HIE Celebrate success in clinical achievements Continue to explore integration models
41 Thank you! Rina Ramirez, MD
42 Integrated Care for People with SMI
43 CHCS Mission Improving the lives of people with mental health disorders, substance use challenges and intellectual and developmental disabilities
44 Trauma Informed Care
45 Client Population Insured Integrated Clinic CHCS ALL MEDICAID 63.3% 49.5% UNFUNDED 24.3% 44.4%
46 Client Population Integrated Clinic CHCS ALL Above Poverty 45% 64% Below Poverty 55% 36%
47 Integration Model The Need Technical Clinical Financial Operational
48 Outcomes Capacity To Serve Patients Improved Clinical Patient Outcomes Patient Experience Improvement
49 Clinical Financial Lessons Learned Structural Policy
50
51 Integrated Care: Zara Suicidal Behaviors Aggressive Outbursts Somatic Complaints Culture & Language Barriers
52 Questions?
Rina Ramirez, MD, FACP Teresita Lawson, BSPharm, RPh, CDE Suyen Segura, MPH, CHES
Rina Ramirez, MD, FACP Teresita Lawson, BSPharm, RPh, CDE Suyen Segura, MPH, CHES 1 Name three approaches that address specific health needs of seniors Discuss how different disciplines may be integrated
More informationNevada County Health and Human Services FY14 Rural Health Care Services Outreach Grant Project Evaluation Report June 30, 2015
Nevada County Health and Human Services FY14 Rural Health Care Services Outreach Grant Project Evaluation Report June 30, 2015 I. Executive Summary The vision of Nevada County Behavioral Health (NCBH)
More informationQUALITY IMPROVEMENT. Molina Healthcare has defined the following goals for the QI Program:
QUALITY IMPROVEMENT Molina Healthcare maintains an active Quality Improvement (QI) Program. The QI program provides structure and key processes to carry out our ongoing commitment to improvement of care
More informationAn Introduction to MPCA and Federally Qualified Health Centers~ Partners for Quality Care
An Introduction to MPCA and Federally Qualified Health Centers~ Partners for Quality Care AIM Partnership Forum June 5, 2014 Lynda C. Meade, MPA Director of Clinical Services Michigan Primary Care Association
More informationIntegration of Behavioral Health & Primary Care in a Homeless FQHC
Integration of Behavioral Health & Primary Care in a Homeless FQHC AtlantiCare Health Services Mission Health Care May 2012 Bridgette Richardson, LCSW Executive Director, AtlantiCare Health Services, Mission
More informationRelationships: The Behavioral Health Consultant, Primary Care Physician, and Psychiatrist i t Healthcare Integration Webinar National Council for Community Behavioral Healthcare February 25, 2010 The Status
More informationHHSC Value-Based Purchasing Roadmap Texas Policy Summit
HHSC Value-Based Purchasing Roadmap Texas Policy Summit Andy Vasquez, Deputy Associate Commissioner MCS, Quality & Program Improvement Section October 19, 2017 1 HHSC Value-Based Purchasing Roadmap Topics
More informationStrategies for Addressing Workforce Issues through Partnerships and Policy: An FQHC-University Partnership. Columbus, Ohio.
College of Social Work Strategies for Addressing Workforce Issues through Partnerships and Policy: An FQHC-University Partnership Staci Swenson, MA, MSW, LISW S Integrated Care Manager PrimaryOne Health
More informationINTEGRATION OF PRIMARY CARE AND BEHAVIORAL HEALTH
INTEGRATION OF PRIMARY CARE AND BEHAVIORAL HEALTH Integrating silos of care Goal of integration: no wrong door to quality health care Moving From Moving Toward Primary Care Mental Health Services Substance
More informationCommunity Health Improvement Plan
Community Health Improvement Plan Methodist Le Bonheur Germantown Hospital Methodist Le Bonheur Healthcare (MLH) is an integrated, not-for-profit healthcare delivery system based in Memphis, Tennessee,
More informationOverview of New Nursing Roles in Whole Person Care. Session 1
Overview of New Nursing Roles in Whole Person Care Session 1 1 Introductions Anne Shields, MHA, RN Associate Director, UW AIMS Center 2 Learning Objectives RN Primary Care Managers Focus Patient Population:
More informationCommunicator. the JUST A THOUGHT. Ensuring HEDIS-Compliant Preventive Health Services. Provider Portal Features. Peer-to-Peer Review BY DR.
WINTER 2016 MHS NEWSLETTER FOR PHYSICIANS Ensuring HEDIS-Compliant Preventive Health Services Here are a few best practice strategies for raising HEDIS and EPSDT onsite review scores, as demonstrated by
More informationIMPLEMENTATION OF INTEGRATED CARE FROM A LEADERSHIP PERSPECTIVE. Tennessee Primary Care Association Annual Conference October 25 26, 2012.
IMPLEMENTATION OF INTEGRATED CARE FROM A LEADERSHIP PERSPECTIVE Tennessee Primary Care Association Annual Conference October 25 26, 2012 Outline I. Brief Overview of Cherokee (Who are we?) II. The Integrated
More informationUnderstanding the Initiative Landscape in Medi-Cal. IHA Stakeholder Meeting September 23, 2016 Sarah Lally, Project Manager
Understanding the Initiative Landscape in Medi-Cal IHA Stakeholder Meeting September 23, 2016 Sarah Lally, Project Manager Agenda Welcome / Introduction Sarah Lally, Project Manager Inland Empire Health
More informationWelcome to the Agency for Health Care Administration (AHCA) Training Presentation for Managed Medical Assistance Specialty Plans
Welcome to the Agency for Health Care Administration (AHCA) Training Presentation for Managed Medical Assistance Specialty Plans The presentation will begin momentarily. Please dial in to hear audio: 1-888-670-3525
More informationCollaborative Care: Case Study of Integrating Primary Care in a Mental Health Setting Beat Steiner MD MPH Brian Sheitman MD
Collaborative Care: Case Study of Integrating Primary Care in a Mental Health Setting Beat Steiner MD MPH Professor of Family Medicine UNC School of Medicine & Associate Medical Director Primary Care Services
More informationPassport Advantage Provider Manual Section 8.0 Quality Improvement
Passport Advantage Provider Manual Section 8.0 Quality Improvement Table of Contents 8.1 Quality Improvement Program 8.2 Clinical Practice Guidelines 8.3 Star s 8.4 Quality of Care Concerns 8.3 Practitioner
More informationIntegrated Behavioral Health Services
Integrated Behavioral Health Services Anitra Walker, LCSW Liz Frye, MD, MPH Integrated Behavioral Health Background SHLI Integrated Care Initiative started in July 2011 2 initial demonstration sites; Focus
More informationMental Health at Mercy Health: Treating the Whole Person. David E. Blair, MD Mercy Health Physician Partners President and CMO
Mental Health at Mercy Health: Treating the Whole Person David E. Blair, MD Mercy Health Physician Partners President and CMO Trinity Health s 22-state diversified system today $17.6B In Revenue 1.3M Attributed
More informationCancer Screening in Primary Care: Lessons from Community Health Centers
Cancer Screening in Primary Care: Lessons from Community Health Centers Dialogue for Action Washington, DC April 11, 2018 Durado Brooks, MD, MPH Managing Director, Cancer Control Intervention American
More informationBest Management Practices In Integrated Behavioral Health/Primary Care Programs
Best Management Practices In Integrated Behavioral Health/Primary Care Programs The 2017 OPEN MINDS Strategy & Innovation Institute Wednesday, June 7, 2017 2:00pm 3:15pm Steve Ramsland, Ed.D., Senior Associate,
More informationUsing population health management tools to improve quality
Using population health management tools to improve quality Jessica Diamond, MPA, CPHQ Chief Population Health Officer CHCANYS Statewide Conference and Clinical Forum Sunday, October 18, 2015 Introduction
More informationMonica Bharel and Jessie M. Gaeta Boston Health Care for the Homeless Program NHCHC May 2014
Monica Bharel and Jessie M. Gaeta Boston Health Care for the Homeless Program NHCHC May 2014 Data analysis at a population level Implications for our care model Facilitated discussion Population management
More informationImplementation of Ohio SBIRT in an Integrated Health Center: Panel Discussion. All Ohio Institute on Community Psychiatry March 25, 2017
Implementation of Ohio SBIRT in an Integrated Health Center: Panel Discussion All Ohio Institute on Community Psychiatry March 25, 2017 SBIRT Panelists: Introduction Ellen Augsperger Director of Ohio SBIRT
More informationSTANDARDS OF CARE HIV AMBULATORY OUTPATIENT MEDICAL CARE STANDARDS I. DEFINITION OF SERVICES
S OF CARE Oakland Transitional Grant Area Care and Treatment Services J ANUARY 2007 Office of AIDS Administration 1000 Broadway, Suite 310 Oakland, CA 94612 Tel: 510. 268.7630 Fax: 510.268-7631 AREAS OF
More informationChecklist for Ocean County Community Health Improvement Plan Implementation of Strategies- Activities for Ocean County Health Centers: CHEMED & OHI
Checklist for Community Health Improvement Plan Implementation of Strategies- Activities for Lead Organizations Activities Target Date Progress to Date Childhood Obesity (4 Health Centers 1-Educate on
More informationLow Income Pool (LIP) Tier One Milestone (STC-61) Application for Enhancement Projects. Submitted by:
2012-2013 Low Income Pool (LIP) Tier One Milestone (STC-61) Application for Enhancement Projects Submitted by: Florida Health Sciences Center, Inc. d/b/a Tampa General Hospital July 31, 2012 1 1. Applicant:
More informationExhibit 1. Medicare Shared Savings Program: Year 1 Performance of Participating Accountable Care Organizations (2013)
Exhibit 1. Medicare Shared Savings Program: Year 1 Performance of Participating Accountable Care Organizations (2013) 24 percent (52 ACOs) earned shared savings bonus 27 percent (60 ACOs) reduced spending,
More informationRN Behavioral Health Care Manager in Primary Care Settings
RN Behavioral Health Care Manager in Primary Care Settings Integrated Care and the Expanding Role of Nurses Seattle Airport Marriott, SeaTac, WA Tuesday, January 9, 2018 The Healthier Washington Practice
More informationTotal Cost of Care Technical Appendix April 2015
Total Cost of Care Technical Appendix April 2015 This technical appendix supplements the Spring 2015 adult and pediatric Clinic Comparison Reports released by the Oregon Health Care Quality Corporation
More informationGateway to Practitioner Excellence GPE 2017 Medicaid & Medicare
Gateway to Practitioner Excellence GPE 2017 Medicaid & Medicare Recognizing and Rewarding Excellent Practices Improving the Health of Gateway Members PRACTICE ELIGIBILITY (see PCMH slide #27 for separate
More informationProviderReport. Managing complex care. Supporting member health.
ProviderReport Supporting member health Managing complex care Do you have patients whose conditions need complex, coordinated care they may not be able to facilitate on their own? A care manager may be
More informationA Hospital-Owned, Facility- Based Medical Home: Lessons from Ellis Medicine
A Hospital-Owned, Facility- Based Medical Home: Lessons from Ellis Medicine Kellie Valenti, FACHE Vice President for Strategic Planning and Program Development Topics Introducing Ellis Medicine Why we
More information10/10/2017. Mythbusters: Primary Care Edition (Expanding Opportunities) Amina Abubakar, PharmD, AAHIVP Olivia bentley, PharmD, CFts, AAHIVP
Mythbusters: Primary Care Edition (Expanding Opportunities) Amina Abubakar, PharmD, AAHIVP Olivia bentley, PharmD, CFts, AAHIVP 1 Disclosures Amina Abubakar, PharmD, AAHIVP, RX Clinic Pharmacy and Olivia
More informationPatient Centered Medical Home: Transforming Primary Care in Massachusetts
Patient Centered Medical Home: Transforming Primary Care in Massachusetts Judith Steinberg, MD, MPH Deputy Chief Medical Officer Commonwealth Medicine UMass Medical School Agenda Overview of Patient Centered
More informationPatient Centered Medical Home The next generation in patient care
Patient Centered Medical Home The next generation in patient care Provider Training Module I OBJECTIVE To explain... What Patient Centered Medical Home is How it works Why it s important Where to begin
More informationMedicaid 101: The Basics for Homeless Advocates
Medicaid 101: The Basics for Homeless Advocates July 29, 2014 The Source for Housing Solutions Peggy Bailey CSH Senior Policy Advisor Getting Started Things to Remember: Medicaid Agency 1. Medicaid is
More informationQuality Measurement Approaches of State Medicaid Accountable Care Organization Programs
TECHNICAL ASSISTANCE TOOL September 2014 Quality Measurement Approaches of State Medicaid Accountable Care Organization Programs S tates interested in using an accountable care organization (ACO) model
More informationThe Affordable Care Act, HRSA, and the Integration of Behavioral Health Services
The Affordable Care Act, HRSA, and the Integration of Behavioral Health Services Indiana Council of Community Mental Health Centers Ft. Wayne, Indiana May 19, 2011 David B. Bingaman, LCSW, ACSW U.S. Department
More informationCertified Community Behavioral Health Centers and New York State s Healthcare Reform: Considerations for Providers
Certified Community Behavioral Health Centers and New York State s Healthcare Reform: Considerations for Providers November 30, 2015 Joshua Rubin HealthManagement.com Plan CCBHC basics NYS Health Reform
More informationINVESTING IN INTEGRATED CARE
INVESTING IN INTEGRATED CARE The Maine Health Access Foundation s 12 year journey (2005 2016) to improve patient centered care in Maine through the Integrated Care Initiative. Table of Contents The MeHAF
More informationPRINCIPAL DUTIES AND RESPONSIBILITIES:
Position Title: Licensed Clinical Social Worker Union Community Health Center (UNION) is one of the largest FQHC s in New York State, serving approximately 38,000 patients from six locations in the central
More informationFrom Reactive to Proactive: Creating a Population Management Platform
Session D9 / E9 From Reactive to Proactive: Creating a Population Management Platform Richard Gitomer, MD Director, Brigham and Women s Primary Care Center of Excellence Vice Chair, Primary Care, Dept.
More informationCMHC Healthcare Homes. The Natural Next Step
CMHC Healthcare Homes The Natural Next Step Partners in Planning A collaborative effort involving Dept. of Social Services (Mo HealthNet) Dept. of Mental Health Primary Care Association (FQHCs) Coalition
More informationCCBHCs 101: Opportunities and Strategic Decisions Ahead
CCBHCs 101: Opportunities and Strategic Decisions Ahead Rebecca C. Farley, MPH National Council for Behavioral Health Speaker Name Title Organization It Passed! The largest federal investment in mental
More informationHendrick Center for Extended Care. Community Health Needs Assessment Implementation Plan
Hendrick Center for Extended Care Community Health Needs Assessment Implementation Plan - 2014-2016 Overview: Hendrick Center for Extended Care ( HCEC ) is a Long Term Acute Care Hospital, within Hendrick
More informationDelaware Perinatal Population. Behavioral Objectives:
A HYBRID INTEGRATED MATERNAL MENTAL HEALTH CARE MODEL: IMPLEMENTATION STRATEGIES AND CHALLENGES FOR AN OUTPATIENT, HOSPITAL-BASED MATERNAL MENTAL HEALTH PROGRAM Megan O Hara, LCSW Malina Spirito, Psy.D.,
More informationNational Council for Behavioral Health. Trauma-informed Primary Care: Fostering Resilience and Recovery Learning Community
National Council for Behavioral Health Trauma-informed Primary Care: Fostering Resilience and Recovery Learning Community Request for Applications INTRODUCTION The National Council for Behavioral Health
More informationProvider Network Management & Clinical Performance Optimization In Population Health Management: Preparing For Value-Based Reimbursement
Provider Network Management & Clinical Performance Optimization In Population Health Management: Preparing For Value-Based Reimbursement #OMPerformance The 2017 OPEN MINDS Performance Management Institute
More informationAppendix 5. PCSP PCMH 2014 Crosswalk
Appendix 5 Crosswalk NCQA Patient-Centered Medical Home 2014 July 28, 2014 Appendix 5 Crosswalk 5-1 APPENDIX 5 Crosswalk The table compares NCQA s Patient-Centered Specialty Practice () standards with
More informationIntegrated Mental Health Care. Questions
Integrated Mental Health Care Closing the gap between what we know and what we do. Jürgen Unützer, MD, MPH, MA Questions Due to the large number of participants, it is not practical to take questions over
More informationThree World Concept of Behavioral Health and Primary Care Integration Part 3 The Clinician Perspective
Three World Concept of Behavioral Health and Primary Care Integration Part 3 The Clinician Perspective Colorado Behavioral Health Association October 3, 2010 Three World Model C. J. Peek suggests that
More informationRed Carpet Care: Intensive Case Management Program for Super-Utilizers
Red Carpet Care: Intensive Case Management Program for Super-Utilizers Alice Stollenwerk Petrulis, MD Linda C. Stokes, PhD The MetroHealth System Picture of MH MetroHealth 750 bed facility includes Rehab,
More informationTufts Health Unify. A One Care plan (Medicare-Medicaid) for people ages March 16, /27/2017 1
Tufts Health Unify A One Care plan (Medicare-Medicaid) for people ages 21-64 March 16, 2017 3/27/2017 1 About Tufts Health Plan Founded in 1979, Tufts Health plan is a nonprofit organization nationally
More informationThe CCBHC: An Innovative Model of Care for Behavioral Health
The CCBHC: An Innovative Model of Care for Behavioral Health B R E N D A G O G G I N S, J D V I C E P R E S I D E N T O A K S I N T E G R A T E D C A R E M I C H A E L D A M I C O, L C S W D I R E C T
More informationTO BE RESCINDED Patient-centered medical homes (PCMH): eligible providers.
ACTION: Final DATE: 09/21/2018 3:40 PM TO BE RESCINDED 5160-1-71 Patient-centered medical homes (PCMH): eligible providers. (A) A Patient-centered medical home (PCMH) is a team-based care delivery model
More informationPPS Performance and Outcome Measures: Additional Resources
PPS Performance and Outcome Measures: PPS Performance and Outcome Measures: This document includes supplemental resources to the content on PPS Performance and Outcome Measures presented at the December
More informationQUALITY IMPROVEMENT PROGRAM
QUALITY IMPROVEMENT PROGRAM EmblemHealth s mission is to create healthier futures for our customers and communities. We will do this by providing members with a broad range of benefits and conscientious
More informationProvider Guide. Medi-Cal Health Homes Program
Medi-Cal Health Provider Guide This provider guide provides information on the California Medi-Cal Health (HHP) for Community-Based Care Management Entities (CB-CMEs), providers, community-based organizations,
More informationAlbany Medical Center. AMCH PPS Clinical & Quality Affairs Committee. Kallanna Manjunath MD, FAAP, CPE Medical Director AMCH PPS August 26, 2015
Albany Medical Center AMCH PPS Clinical & Quality Affairs Committee Kallanna Manjunath MD, FAAP, CPE Medical Director AMCH PPS August 26, 2015 AMCH PPS: Clinical & Quality Affairs (CQA) Committee Presentation
More informationPatient-centered medical homes (PCMH): Eligible providers.
ACTION: Final DATE: 09/20/2016 8:11 AM 5160-1-71 Patient-centered medical homes (PCMH): Eligible providers. (A) A Patient-centered medical home (PCMH) is a team-based care delivery model led by primary
More informationPopulation Health: Physician Perspective. Kallanna Manjunath MD, FAAP, CPE Medical Director AMCH DSRIP September 24, 2015
Population Health: Physician Perspective Kallanna Manjunath MD, FAAP, CPE Medical Director AMCH DSRIP September 24, 2015 Population Health: Physician Perspective Presentation objectives: Brief Bio Population
More informationSECTION 3. Behavioral Health Core Program Standards. Z. Health Home
SECTION 3 Behavioral Health Core Program Standards Z. Health Home Description Health home is a healthcare delivery approach that focuses on the whole person and provides integrated healthcare coordination
More informationMission: Providing excellent health care to American Indians. Vision: To be the national model for American Indian Health Care
Mission: Providing excellent health care to American Indians Vision: To be the national model for American Indian Health Care Core Values: Patient First, Quality, Integrity, Professionalism and Indian
More informationMedical Management. G.2 At a Glance. G.3 Procedures Requiring Prior Authorization. G.5 How to Contact or Notify Medical Management
G.2 At a Glance G.3 Procedures Requiring Prior Authorization G.5 How to Contact or Notify Medical Management G.6 When to Notify Medical Management G.11 Case Management Services G.14 Special Needs Services
More informationOffice of Mental Health Continuous Quality Improvement Initiative for Health Promotion and Care Coordination: 2013 Project Activities and
Office of Mental Health Continuous Quality Improvement Initiative for Health Promotion and Care Coordination: 2013 Project Activities and Expectations March 2013 Overview Welcome 2013 CQI Project Options
More informationConnecticut SIM: Enabling Accountable Care and Accountable Communities
Connecticut SIM: Enabling Accountable Care and Accountable Communities SIM SYMPOSIUM FROM ACCOUNTABLE CARE TO ACCOUNTABLE COMMUNITIES: HOW CONNECTICUT S STATE INNOVATION MODEL INITIATIVE IS DRIVING REFORM
More informationArkansas Blue Cross and Blue Shield Patient Centered Medical Home Provider Manual
Arkansas Blue Cross and Blue Shield Patient Centered Medical Home Provider Manual 2017 This document is a guide to the 2017 Arkansas Blue Cross and Blue Shield Patient-Centered Medical Home program (Arkansas
More informationCovered Services List and Referrals and Prior Authorizations for MassHealth Members enrolled in Partners HealthCare Choice
Covered Services Covered Services List and s and Prior Authorizations for MassHealth Members enrolled in Partners HealthCare Choice This chart tells you two things: 1. the covered services and benefits
More informationValue-based Care Report. February How Value-based Care is improving quality and health.
Value-based Care Report February 2018 How Value-based Care is improving quality and health. 1 Value-based Care means better health, better care and lower costs. Placing greater emphasis on value in health
More informationPCA/HCCN Health Center Program Update
PCA/HCCN Health Center Program Update National Association of Community Health Centers Community Health Institute August 30, 2016 Tonya Bowers, MHS Acting Associate Administrator Bureau of Primary Health
More informationTABLE OF CONTENTS. Primary Care 3. Child Health Services. 10. Women s Health Services. 13. Specialist Health Services 16. Mental Health Services.
TABLE OF CONTENTS Primary Care 3 Child Health Services. 10 Women s Health Services. 13 Specialist Health Services 16 Mental Health Services. 24 2 PRIMARY CARE What is it? Primary care is a patient's first
More informationCommunity Health Needs Assessment: St. John Owasso
Community Health Needs Assessment: St. John Owasso IRC Section 501(r) requires healthcare organizations to assess the health needs of their communities and adopt implementation strategies to address identified
More informationSt. Mary Medical Center, Langhorne, PA Community Health Needs Assessment Implementation Strategy Fiscal Year 2018
St. Mary Medical Center, Langhorne, PA Community Health Needs Assessment Implementation Strategy Fiscal Year 2018 St. Mary Medical Center (St. Mary) completed a comprehensive Community Health Needs Assessment
More information700 E. Jefferson Street, Suite 100 Phoenix, AZ (602)
700 E. Jefferson Street, Suite 100 Phoenix, AZ 85034 (602) 253-0090 www.aachc.org History of Health Care Quality Models History of Quality Initiatives/Models are all over the Board! Statistical Quality
More informationThe Health Center Program Quality Improvement
The Health Center Program Quality Improvement National Network for Oral Health Access Annual Conference November 8, 2016 Vy Nguyen, DDS, MPH Dental Officer, Office of Quality Improvement Bureau of Primary
More informationPCSP 2016 PCMH 2014 Crosswalk
- Crosswalk 1 Crosswalk The table compares NCQA s Patient-Centered Specialty Practice (PCSP) 2016 standards with NCQA s Patient-Centered Medical Home (PCMH) 2014 standards. The column on the right identifies
More informationNational Committee for Quality Assurance
National Committee for Quality Assurance (NCQA) Private, independent non-profit health care quality oversight organization founded in 1990 MISSION To improve the quality of health care. VISION To transform
More informationATTACHMENT II EXHIBIT II-C Effective Date: February 1, 2018 SERIOUS MENTAL ILLNESS SPECIALTY PLAN
ATTACHMENT II EXHIBIT II-C Effective Date: February 1, 2018 SERIOUS MENTAL ILLNESS SPECIALTY PLAN The provisions in Attachment II and the MMA Exhibit apply to this Specialty Plan, unless otherwise specified
More informationSHOW-ME INNOVATION: Missouri s Health Care Homes Integrate Behavioral Health and Primary Care Jaron Asher, MD February 28, 2014
SHOW-ME INNOVATION: Missouri s Health Care Homes Integrate Behavioral Health and Primary Care Jaron Asher, MD February 28, 2014 Jaron Asher, MD Medical Director at Places for People in St. Louis, MO Chief
More information2016 Community Health Needs Assessment Implementation Plan
2016 Community Health Needs Assessment Following the 2016 Community Health Needs Assessment, Saint Mary s Hospital developed an Implementation Strategy to illustrate the hospital s specific programs and
More informationIntegration Models Lessons From the Behavioral Health Field
Integration Models Lessons From the Behavioral Health Field Presenters: Karen Bassett, Weber Human Services Kathy Bianco, Care Plus NJ, Inc Jennifer DeGroff, AspenPointe The Wellness Clinic Weber Human
More informationCommunity Mental Health and Care integration. Zandrea Ware and Ricardo Fraga
Community Mental Health and Care integration Zandrea Ware and Ricardo Fraga One in Five Approximately 1 in 5 adults in the U.S. 43.8 million, or 18.5% experiences mental illness in their lifetime. Community
More informationHEALTH CARE REFORM IN THE U.S.
HEALTH CARE REFORM IN THE U.S. A LOOK AT THE PAST, PRESENT AND FUTURE Carolyn Belk January 11, 2016 0 HEALTH CARE REFORM BIRTH OF THE AFFORDABLE CARE ACT Health care reform in the U.S. has been an ongoing
More informationPhysical Health Integration Within Behavioral Healthcare: Promising Practices
Physical Health Integration Within Behavioral Healthcare: Promising Practices 9:45 AM 10:45 AM Steering Toward Success: Achieving Value in Whole Person Care September 25 and October 26, 2017 The Healthier
More informationPatient-Centered. Medical Homes (Presentation Handout)
Patient-Centered Medical Homes (Presentation Handout) Presented to AFC SPC, 3/14/13 by Barbara Schechtman, MPH 1 What is a PCMH? From the March 2007 Joint Principles of the PCMH: AAP, American Academy
More informationArkansas Blue Cross and Blue Shield Patient Centered Medical Home Provider Manual
Arkansas Blue Cross and Blue Shield Patient Centered Medical Home Provider Manual 2016 This document is a guide to the 2016 Arkansas Blue Cross and Blue Shield Patient-Centered Medical Home program (Arkansas
More informationBehavioral Health Providers: The Key Element of Value Based Payment Success
Behavioral Health Providers: The Key Element of Value Based Payment Success December 6, 2017 Presented by: Andrew Cleek, Psy.D. Meaghan Baier, LMSW Goals of the Presentation Understand the intersect between
More informationValue-based Care Report. February How Value-based Care is improving quality and health.
Value-based Care Report February 2018 How Value-based Care is improving quality and health. Value-based Care delivers: Value-based Care means better health, better care and lower costs. Placing greater
More informationTransforming Healthcare Delivery, the Challenges for Behavioral Health
Transforming Healthcare Delivery, the Challenges for Behavioral Health Presented by: M.T.M. Services, LLC P. O. Box 1027, Holly Springs, NC 27540 Phone: 919-434-3709 Fax: 919-773-8141 E-mail: mtmserve@aol.com
More informationVISION Every Rhode Islander has equal access to affordable, quality, comprehensive health care.
Rhode Island Health Center Association 235 Promenade Street, Suite 455 Providence, RI 02908 Phone (401) 274-1771 Fax (401) 274-1789 www.rihca.org 2010 / 2011 Mission The Rhode Island Health Center Association
More informationQuality Management (QM) Program AmeriHealth Pennsylvania
Quality Management (QM) Program AmeriHealth Pennsylvania Goals and Objectives The goals and objectives of the Quality Management (QM) Program are to promote the quality and safety of medical and behavioral
More informationFostering Effective Integration of Behavioral Health and Primary Care in Massachusetts Guidelines. Program Overview and Goal.
Blue Cross Blue Shield of Massachusetts Foundation Fostering Effective Integration of Behavioral Health and Primary Care 2015-2018 Funding Request Overview Summary Access to behavioral health care services
More informationPCMH 2014 Recognition Checklist
1 PCMH1: Patient Centered Access 10.00 points Element A - Patient-Centered Appointment Access ~~ MUST PASS 4.50 points 1 Providing same-day appointments for routine and urgent care (Critical Factor) Policy
More informationBuilding Connective Tissue for Integrated Care The Unfolding NH Medicaid Story. April 17, 2018
Building Connective Tissue for Integrated Care The Unfolding NH Medicaid Story April 17, 2018 Who Are We Supporting In IDN-1? Source: MAeHC Analysis, NH Medicaid IDN Region 1 Data Book Release 1 Findings:
More informationTennessee Health Care Innovation Initiative
March 8, 2016 1 Tennessee Health Care Innovation Initiative It s my hope that we can provide quality health care for more Tennesseans while transforming the relationship among health care users, providers
More informationCommunity Health Needs Assessment IMPLEMENTATION STRATEGY. and
2015-2018 Community Health Needs Assessment IMPLEMENTATION STRATEGY and Collaborative Health Improvement Plan Palisades Medical Center Implementation Strategy - 1- Introduction: Palisades Medical Center
More informationVHA Transformation to a Patient Centered Medical Home Model of Care
VHA Transformation to a Patient Centered Medical Home Model of Care Joanne M. Shear MS, FNP-BC VHA Primary Care Clinical Program Manager Office of Primary Care Operations & Policy Washington, DC Joanne.shear@va.gov
More informationPatient-centered medical homes (PCMH): eligible providers.
ACTION: Final DATE: 09/21/2018 3:40 PM 5160-1-71 Patient-centered medical homes (PCMH): eligible providers. (A) A Patient-centered medical home (PCMH) is a team-based care delivery model led by primary
More informationQuality Incentive Programs. By: Amy Yearwood RN, BSN Physicians Network Quality Manager Huntsville Hospital
Quality Incentive Programs By: Amy Yearwood RN, BSN Physicians Network Quality Manager Huntsville Hospital Housekeeping 1. Using the control panel - Use the control panel on the right side of your screen
More information