Behavioral Health Integration in the Primary Care Setting

Transcription

1 Behavioral Health Integration in the Primary Care Setting Rajvee Vora, MD,MS Director, Ambulatory Behavioral Health for DSRIP Implementation Health Solutions, Northwell Health Assistant Professor, Department of Psychiatry Hofstra Medical School 1

2 Agenda 1. Northwell Health and Integrated Care 2. Implementing Integrated Care 3. Measuring Success 4. Barriers & Challenges 5. Lessons Learned 6. Recommendations for Replication 10/5/2017 2

3 Northwell Health and Integrated Care About Northwell Health Genesis of the Program Behavioral Health Team 10/5/2017 3

4 About Northwell Health Clinical Care Delivery Education Research Population Health Community Health Joint Ventures 10/5/2017 4

5 About Northwell Health Northwell Health Solutions is our care management organization that implements and stewards the health system's value based care programs. Northwell Health Solutions supports physicians and other providers in patient care. Complex Care Management Behavioral Health Care Management Advanced Illness Management Health Solutions Transitional Care Management Disease Management Medicaid Health Home 10/5/2017 5

6 Genesis of the Program Delivery System Reform Incentive Payment (DSRIP) Quality Cost Population A unique opportunity to address the underlying challenges facing NYS health care delivery: Increase Access to Primary Care Reduce Avoidable Hospital/ED Utilization Behavioral Health Integration Project Community Crisis Stabilization Project 10/5/2017 6

7 Genesis of the Program -DSRIP 3.a.i. Integration of Primary Care and Behavioral Health Project Requirements Co-locate behavioral health providers in primary care practices Primary care practices screen 90% of patients using evidence-based tools Co-locate primary care providers in behavioral health outpatient practices, Article 31 sites Project Quality Metrics Screening for Clinical Depression and follow-up (P4R in year 2/3) Follow-up care for Children Prescribed ADHD Medications - Continuation Phase (P4R in year 2/3) Potentially Preventable Emergency Room Visits (for persons with BH diagnosis) Quality metrics related to DM and Schizophrenia and psychotropics 10/5/2017 7

8 Behavioral Health Team Director Program Management Psychiatrists BH Care Management Program Manager Psychiatrist #1 Supervisor Project Manager Psychiatrist #2 9 BH Care Managers 10/5/2017 8

9 Behavioral Health Team PCP BH Care Manager Consulting Psychiatrist Identify & Refer Patients to the BH Care Manager Initiate medications if necessary and as recommended by the BH care team Get curbside consults from Psychiatrist Include the BH Care Manager in team meetings Complete initial assessments (~60 min) Provide PCP with Tx recommendations after consultation with psychiatrist. Conduct brief (~30 min) follow-up sessions with enrolled patients Refer patients to a higher level of care if needed Provide PCP with curb-side consultation Supervise BH Care Managers weekly and adhoc to give treatment recommendations 10/5/2017 9

10 Behavioral Health Team PCP Patient BH Care Manager Consulting Psychiatrist Frequent Contact Infrequent Contact 10/5/

11 Implementing Integrated Care Roadmap to Integration 10/5/

12 Roadmap to Integration Pre-Integration Care Manager Intro Monitor & Improve Integration Preparation Care Manager Services 12

13 Phase 1: Pre-Integration Readiness Assessment Introduction to Integrated Care Integrated Care Toolkit PHQ Screening 1 13

14 Readiness Scale Score Is a Physician Leader and Champion available? None Possible Interested Available and ready Does the practice use an electronic medical record? Is office space available for a Behavioral Health Consultant? How comfortable are the Primary Care Physicians with providing behavioral health care? Is a physician in the practice interested in Education and Training? Are any Behavioral Health Screenings being done? Is the practice involved in Patient Centered Medical Home (PCMH) certification? Are there Team Meetings or Huddles that a Behavioral Health Consultant can participate in? Is there any linkage to community providers/resources? Do you track the high risk/vulnerable population? Is the practice interested in the integration of Behavioral Health? None Plans for EMR EMR but hard to modify None Can work to modify Possible Available and ready Available and ready Not at all A little Often Very Comfortable Not at all A little Maybe Very Interested No PHQ2/SBIRT PHQ9 All of the above and more No Beginning Level II Level III No Infrequently Frequently Regularly scheduled No A little Often Closely linked No A little Sometimes Yes No Not sure A little Yes 10/5/

15 PHQ Screening 90% of Patients Screened with the PHQ-2 or PHQ

16 Data and Transparency 1 16

17 Phase 2: Integration Preparation Workflow Development & Mapping 1 17

18 Phase 3: Care Manager Intro Kickoff Meeting Care Manager Schedule 1 Site Walkthrough 18

19 Phase 4: Care Manager Services BH Care Manager begins treating Patients BH Care Manager will document in the AEHR and a custom registry that monitors treatment progress. 1 19

20 Phase 5: Monitor & Improve Key Performance Indicators 1. PHQ Screening Rate for the Practice 2. Total Enrollment 3. Active Patients 4. Crisis Encounters 5. Referrals to outside BH resources 1 Monthly Check-Ins Practice Dashboard Clinical Services 20

21 Measuring Success Clearly Defined Goals Registries Accountable Care Analytics 10/5/

22 Measuring Success Access Enrollment Improvement Referrals Crisis Encounters Goal Increase access to behavioral health resources Appropriate balance of patients managed in the program Track Patient outcomes and improvement measures Ensure Patients receive the appropriate level of care Reduce avoidable ED visits Metric Number of patient encounters BH Care Manager s active caseload (~60-80) and encounters per day PHQ-9 & GAD-7 Improvement Rate (%) Track referrals made by BH Care Manager The number of successful de-escalations 10/5/

23 Measuring Success Development of a Patient Registry is a critical element to gauge success 10/5/

24 Measuring Success Behavioral Health Care Manager Registry 10/5/

25 Measuring Success Treatment Overview 10/5/

26 Measuring Success Key Performance Indicators 10/5/

27 Measuring Success Monitor Trends 10/5/

28 Measuring Success Crisis Encounters & ED Visits 10/5/

29 Measuring Success Patient Demographics 10/5/

30 Barriers & Challenges Risks to Implementation and Sustainability 10/5/

31 Barriers & Challenges Change in Culture Inappropriate Referrals to BH Care Manager Finding Referral Sources for high-needs Patients Reimbursement Licensing/Regulation Barriers 10/5/

32 Success & Lessons Learned 10/5/

33 Success & Lessons Learned Integrated sites September /5/

34 Success & Lessons Learned Integrated sites September 2017 Integrated Care is provided at 27 PCP offices 10/5/

35 Successes & Lessons Learned Developed an inter-disciplinary behavioral health team with 9 BH Care Managers Integrated Care is provided at 27 Primary Care Locations Developed an in-house registry and interactive dashboard to track patient outcomes Over 1,000 patients have received behavioral health treatment since Sept 2016 Significant increase in PHQ screening rates at integrated PCP locations Increased Patient and Provider satisfaction Secured buy-in from senior leadership across multiple service lines Patient-Centered Care 10/5/

36 Recommendations for Replication 10/5/

37 Recommendations for Replication 1 Assess the Need Assess current needs and available resources 2 Decide on a Team-Based Care Model Models vary depending on patient needs and practice capabilities. 3 4 Train and Educate Train all members of the Primary Care Team. Monitor Monitor outcomes and improve processes 10/5/

38 Replication- Models of Co-location and Integration Co-location: Volume and access Financial Sustainability Collaborating partners-cbos, private practitioners Licensure and hiring Integration Ability to hire Partner with Primary Care Physicians Hiring a Consultant Psychiatrist Program management and Data analysis is crucial 10/5/

39 10/5/

40 Questions? 10/5/