Collaborative Care: Case Study of Integrating Primary Care in a Mental Health Setting Beat Steiner MD MPH Brian Sheitman MD
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1 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 Wakebrook Brian Sheitman MD Professor of Psychiatry UNC School of Medicine & Medical Director Wakebrook
2 Objectives Examine a reverse co-location model of collaborative care Identify important features of model Present challenges and stimulate discussion on how to overcome challenges Identify others who might be interested in helping us improve this model
3 The Case for Integrated Care People with severe mental Illness die 25 years earlier than the general population (on average) (60% due to physical health conditions COPD, CAD, Cancer)
4 Why Reverse Co-Location? Medical home in a community based outpatient practice is right for most patients but not all patients. Patients with severe mental illness:» often need for frequent mental health services» may require specialized care: ability to connect with community mental health resources team based care with focus on behavioral health ability to deal with crisis» may feel more comfortable in behavioral health setting
5 Inpatient Unit: 16 beds (soon to be expanded to 28)» admits per year Residential Facility Based Crisis Unit: 16 beds» 500 admits per year Residential Detox Unit: 16 beds» 900 admits per year; #1 alcohol, #2 opioids Crisis and Assessment Services: 12 chairs» 5000 patients per year Child Psychiatry Clinic Substance abuse treatment program for pregnant and/or parenting women and their children Primary Care Service WakeBrook
6 WakeBrook Primary Care Service Staffing:» MD Medical Director: 0.4 FTE» MD supervision: 1.0 FTE» FNP/PA: 3.5 FTE Description of Work:» Intake physicals and consultations on units» Full scope outpatient family medicine office for patients with SMI Coordinated and accessible care over time Focus on quality improvement Team based care with behavioral health
7 Needs Identified on Units 24% 11% 9% 4% HTN COPD/Asthma DM 55% 34% 20% no care X2 years ED visit for dental care current pain CV Dz 77% 74% need CRC 64% 46% 42% use Tobacco need Mammo need Pap need PCP
8 Early Impact of our Work on Units 40 ED transfers/month from Wakebrook for Medical Reasons q q q q q q q q q q ED transfers per month
9 Our Primary Care Practice Team Flex clinicians who work on units Full time RN with care manager role Full time office manager with quality improvement role Pharmacy technician (50%) Dental team (dental students with faculty supervision) Peer support (100%) Note: positions in red being added currently (SAMHSA funded) start up funds provided by UNC HCS and Wake County
10 Growing the Primary Care Office Current Total Panel Size: 238 Goal: August 2014 September 2014 October 2014 November 2014 December 2014 January 2015 February 2015 March 2015 April 2015 May 2015 June 2015 July 2015 August 2015 Visits Per Month No Shows Per Month
11 The Clients in our Primary Care Office Physical Health Diagnoses n % HTN % DM 43 18% COPD 25 11% CAD 10 4% Psychiatric Diagnoses n % Psychotic Disorder % Severe Mood Disorder 22 9% Personality Disorder 20 8% Substance Use Disorder 56 24% Insurance Status (%) Medicaid 28% Dual 16% Medicare 26% Other Govt 5% Private 3% Uninsured 22% Behavioral Health Connection UNC ACT team Fellowship ACT team Easter Seals ACT team Carolina Outreach ACT team STEP clinic Naftel WakeMed n % 47 20% 5 2% 2 1% 5 2% 60 25% 15 6% 6 3%
12 Triple Aim Dashboard for Quality 9/1/2015 Population Health n % Tobacco Use % BMI > % DM with systolic > % DM with A1c >9 5 12% HTN with SBP > % eligible women with Pap q3 yrs pend pend patients >50 with CRC screen pend pend Cost n % Emergency room visits past 3 mo pend pend Hospitalization past 3 months pend pend Patient Experience n % Time to third available appt pend pend Cycle time pend pend Patient satisfaction pend pend
13 Challenges Develop long term financial viability» Contracts that pay for value not for volume» Collect data for utilization outside of our office Find most effective and efficient ways to communicate with behavioral health team Measure patient experience
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