Healthcare Transformation at. Cherokee Health Systems

Transcription

1 Dennis S. Freeman Chief Executive Officer Cherokee Health Systems Healthcare Transformation at Cherokee Health Systems Blending Behavioral Health Providers into the Patient-Centered Medical Home Speaker Name Title Organization

2 A Brief History of Integrated It s the same each time with progress. First they ignore you, then they say you re mad, then dangerous, then there s a pause and then you can t find anyone who disagrees with you. - Tony Benn, English politician

3 Healthcare Transformation at Cherokee Health Systems Blending Behavioral Health into the Patient-Centered Medical Home Transforming the Delivery of Behavioral Healthcare Enhancing the Patient Centered Medical Home

4 Cherokee s Patient-Centered Medical Home Embedded Behavioral Health Consultant on the PC Team Real time behavioral and psychiatric consultation available to PCP Focused behavioral intervention in primary care Behavioral medicine scope of practice Encourage patient responsibility for healthful living A behaviorally enhanced Patient-Centered Healthcare Home

5 Behaviorally Enhanced PCMH Blended care team Shared patient panel and population health goals BH Access and collaboration at point of PC visit Co-management and care coordination by Team Shared clinical documentation, communication, treatment planning

6 The Nature of Primary Main point of access to care for all healthcare, including behavioral health conditions Principal setting for treatment of behavioral health conditions Locus of bi-directional interplay of medical and behavioral disorders, health behaviors, social determinants Behavioral Healthcare - ROUTINE component of primary care

7 Behavioral Health Consultant (BHC) Scope of Practice Application of behavioral principles to address lifestyle and health risk issues Management of psychosocial aspects of chronic and acute diseases Consultation and co-management in the treatment of mental disorders and psychosocial issues

8 Community Health Coordinators Enhancing the Role of Case Managers Field-based member of the care team Build patient engagement Expand health literacy Promote self-management Disease management in the field

9 The Integrated Psychiatrist Access and population-based care Enhance skills of primary colleagues Consultative to PCPs and BHCs Fast track access to patient for stabilization Stabilize patients and return to primary care

10 Resource Linking Community Health Coordinator PCMH Work Flow Integrated Team Acute Nursing Assistants Medication Refills Preventive PSR Medication Reconciliation Nurses Transitions Behavioral/ Substance Use Screenings Coordinators Chronic Disease Management Behavioral Treatment Behavioral Health Consultant Provider Medical Social Family History Patient Engagement Health Coach Self Management Goals Gaps in Pharmacist

11 Integrated Team Health Coach Community Health Coordinator Preventive Chronic Disease Management Medication Refills Transitions Resource Linking Patient Engagement Medical Social Family History Gaps in Coordinators Self Management Goals PSR PATIENT Self Management Goals Gaps in Gaps in Patient Engagement Patient Engagement Patient Engagement Medication Refills Medication Refills Appointment Coordination Preventive Preventive Preventive Resource Linking Self Management Goals Transitions

12 PCMH Work Flow Integrated Team Pharmacist Nursing Assistants Provider Behavioral Health Consultant Nurses Medication Reconciliation Medication Refills Transitions Patient Engagement Chronic Disease Management Gaps in Medical Social Family History Resource Linking Medication Reconciliation Patient Engagement Medication Reconciliation Medication Refills Acute Plan of Patient Engagement Behavioral/ Substance Use Screenings Self Management Goals Behavioral Intervention Transitions Acute Patient Engagement Acute Preventive Medication Reconciliation Medication Refills Transitions Chronic Disease Management Patient Engagement

13 Resource Linking Medication Refills Community Health Coordinator PCMH Work Flow Integrated Team Pharmacist Coordinators PSR Acute Behavioral/ Substance Use Screenings Medication Reconciliation Nursing Assistants PATIENT Behavioral Health Consultant Self Management Goals Medical Social Family History Nurses Health Coach Provider Preventive Behavioral Treatment Chronic Disease Management Patient Engagement Gaps in Transitions

14 How The Team Coordinates And Communicates Patient Dashboard Morning Huddles Communication from Coordination in EHR Weekly Integrated Team Meetings Standing Orders HEDIS Measure Outcome Sharing Site Specific Quality Improvement Activities

15 Patient Dashboard Purpose To ensure the interdisciplinary team has a comprehensive snap shot of the patient s treatment needs and plan Team Self Management Goals Coordination Diagnoses Vaccines Referrals Medications Hospital ER/Admissions Point of (Guidelines) Gaps in Labs Vital Signs Allergies Portal Enrollment Status

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18 Executive Dashboard Reports Sample Data

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20 Our Mission To improve the quality of life for our patients through the blending of primary care and behavioral health. Together Enhancing Life

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24 First Glimpses of the Vision Primary care is behavioral healthcare Comorbidities are a challenge Provider collaboration is powerful Silo-based training yields silo-based practice Referrals to mental health usually fail Primary care -- best platform for community mental health programming

25 Cherokee Health Systems Forks in the Road/Epochs of Development Rooted in the mission of community mental health Circuit riding outreach into primary care Primary care operations Embedded Behavioral Health Consultant role Blending the cultures, becoming an FQHC Behaviorally enhanced Healthcare Home

26 We sure were lost but we were making good time! - Yogi Berra

27 Critical Success Factors for Effective and Sustainable Integration Secure the financial model Establish efficient clinical workflow Find effective behaviorists Adopt a culture of integration

28 Reflections On 47 Years of Integrated I. Patients always point the way. II. Never let the manifest demand obscure the unpresented need. III. Integration is a means to an end, not an end unto itself. IV. Mission is the compass. V. Just do it! VI. The status quo is never good enough. VII. Not every Behaviorist can make it in primary care. VIII. It s hard to have perspective working in a silo. IX. Contracting is a high stakes game. X. Bring value: Always strive to serve the greater good.

29 Contact Information: Dennis S. Freeman, Ph.D. Chief Executive Officer Cherokee Health Systems 2018 Western Avenue Knoxville, Tennessee Phone: (865) Fax: (865)