Implementation workflows in a large, complex, multi-specialty residency training site Workflows in EMR that enhance communication across our system
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- Wesley Griffin
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1 Implementation workflows in a large, complex, multi-specialty residency training site Workflows in EMR that enhance communication across our system Foundation on which we started this initiative; our psychosocial team, some evaluation processes, supervision, & related tools Barriers, challenges and how we addressed these Preliminary outcomes & program sustainability
2 CHCANYS Annual Meeting MMG-CFCC/ BCHN 10/24/12
3 Health Center since providers Primary care : Internal Medicine, Pediatrics, Women s Health & Low Risk Obstetrics Specialty care: Adult & Pediatric Specialties, High Risk Obstetrics & Gynecology, Dental Added services: Mental Health & Psychosocial Services, Nutrition, Health Education Major graduate medical education training site for Montefiore Medical Center 33,317 users and 109,000 visits (including Dental) in % Hispanic, 31% Black, 11% White, 2% Asian, 19% combined ethnicities or unreported 3,000 visits of patients with anxiety & depression already identified in 2010
4 Health center with co-located social services in each clinical unit Psycho-social mental health team development Inter/ intra-disciplinary & community service teamwork for HIV+ prenatals & their families Various collaborative initiatives (Pediatric health care maintenance, Prenatal Care, Asthma, Diabetes, Obesity, etc.) built on the IHI & HRSA encouraged Care Model since 2003 Chronic care teams screen patients w/dm & HTN using PHQ9 Interdisciplinary team meetings across health center in all units
5 NAME ORGANIZATIONAL ROLE TEAM ROLE Carol N. Lau, FNP Administrative Director, CFCC Project Director Valerie Ward, LCSW-R Manager of Social Services, Health Education & Nutrition, CFCC Team Leader Dr. Marta Rico, Medical Director Drs. Ariela Frieder & Julianne Suojanen, Psychiatrists Medical Director, Adult Medicine, CFCC Part-time Psychiatrists, CFCC Physician Champion/ Faculty Liaison Consulting Psychiatrists Maria Lopez, LMSW Project Impact Care Manager, CFCC Care Manager Obdulia Fontanez, LMSW Unit Social Worker, Medicine, CFCC Unit Social Worker, Adult Medicine Joanna White, RN, ANM Administrative Nurse Manager, CFCC ANM Patricia Lopez, CHES Health Educator Health Educator Renee Whiskey, MPH, CHES Community Health Educator, BCHN Liaison support Gay Goodfriend, BS Data Manager, BCHN Data support
6 To Patients Reception Area Presentations (RAPs) Pre & post tests to gauge patient s knowledge & understanding Public displays of storyboards & easily accessible brochures To Providers & Staff Team met all staff, faculty & residents Medical director highlighted importance of PHQ9 screening & collaboration w/all of PI care team Distributed info to all
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8 ROLE Be Proactive, Accessible, Approachable and Flexible Team Collaboration with all staff and providers TECHNIQUES Problem Solving Therapy Behavioral Activation Therapy In office AND telephone sessions Individuals & groups
9 BASELINE INFO Project Impact patients w/ HTN = 165, Improved PHQ9= 79 And controlled BP below 140/90 Successful PIC enrollees exceeded the patients not enrolled (Total patients w/htn=1486) DATA
10 BASELINE INFO Project Impact patients w/dm = 111, Improved PHQ9= 53 And controlled HbA1c (<=9%) Successful PIC enrollees exceeded the patients not enrolled (Total patients w/dm=2061) DATA
11 CHALLENGES Infrequent patient visits Transportation and escort problems Lack of commitment to 6-8 sessions in person Stigmas about mental health treatment SOLUTIONS Care Manager sees patients same days as other appointments Modified Treatment Module telephone sessions
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13 Electronic Medical Record implemented Oct 2010, & evolving imbedded PHQ 2s and 9s Social Work billing initiated; credentialing completed Patient Centered Medical Home, NCQA accredited 2010, level 3 for 2008 standards standards coming up next year. Developing Behavioral Health Service- Delivery across Montefiore Medical Group network, based on the Project Impact model
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