Social Innovation Fund (SIF) Training. Seattle, Washington October 10, 2016

Transcription

1 Social Innovation Fund (SIF) Training Seattle, Washington October 10, 2016

2 Welcome & Introductions University of Washington AIMS Center

3 Welcome & Introductions John A. Hartford Foundation Mary Jane Koren, MD Program Consultant

4 Clinic Introductions

5 Agenda Time Topic Location 8:30 Welcome, Introductions, Updates Cedar 9:45 Break 10:00 Overcoming Challenges Cedar 11:45 Lunch 12:45 Engaging Men in Depression Care Cedar 1:30 Break 1:45 Breakout A: Group PST Cedar 1:45 Breakout B: Roundtable Q&A Alder 3:00 Break 5:00 Adjourn

6 Facilities & Materials Bathrooms Lunch location Folder Name Tags Sign in sheets Evaluations

7 Social Innovation Fund We ve Come a Long Way Together Diane Powers, MA Jürgen Unützer, MD, MA, MPH

8 Timeline Nov 2011 Mar 2012 July 2012 Nov 2012 June 2013 Sept 2013 Oct 2013 June 2014 Sept 2014 Sept 2015 June 2016 Sept 2016 JAHF and UW began collaboration on grant application Grant submitted to CNCS Grant awarded RFA published by JAHF Cohort 1 clinics receive grants from JAHF First In person Training; Cohort 1 clinics launch Second RFA published by JAHF Cohort 2 clinics receive grants from JAHF Second In person Training; Cohort 2 clinics launch Third In person Training Cohort 1 completes initial 3 year grant period Final In person Training

9 SIF Initiative Overview CNCS Corporation for National and Community Service SIF Social Innovation Fund GRANTEE The John A. Hartford Foundation Contractor: University of Washington AIMS Center SUB GRANTEE WWAMI Rural Primary Care Clinics

10 Why WWAMI? Why Rural? Source County Health Rankings, Robert Wood Johnson Foundation and University of Wisconsin Population Health Institute

11 FQHCs nation s largest and fastest growing primary care network 8,000 clinics 20 million patients FQHCs are safety net 72% FQHC patients live in poverty 49% live in rural areas 36% uninsured 67% from racial/ethnic minority populations

12 Mental Health in FQHCs Mental health most commonly reported reason for visit Only 5.5% of visits include on site mental health specialist Counselor / therapist Clinical social worker Psychologist Psychiatric nurse practitioner Psychiatrist Rare in rural areas

13 Collaborative Care (aka IMPACT) Evidence based model for treating behavioral health conditions in primary care

14 Evidence based Treatments Individualized tx plan includes one or both Medications Consultant helps PCPs expand capacity Psychotherapy Modalities appropriate for primary care Brief Structured Strong evidence

15 IMPACT Summary Less depression IMPACT more than doubles effectiveness of usual care Less physical pain Better functioning Higher quality of life Greater patient and provider satisfaction More cost effective TRIPLE AIM I got my life back

16 Paradigm Shift Evidence based integrated care NOT simply specialty BH services grafted onto primary care PRIMARY CARE behavioral health Requires all providers to actively collaborate with a shared care plan, not simply practice in parallel

17 Co Location Is NOT Enough 50% or greater improvement in depression at 12 months % Participating Organizations

18 Principles of Collaborative Care Patient Centered Collaboration. Primary care and mental health providers collaborate effectively using shared care plans. Population Based Care. A defined group of patients is tracked in a registry so that no one falls through the cracks. Treatment to Target. Progress is measured regularly and treatments are actively changed until clinical goals are achieved. Evidence Based Care. Providers use treatments that have research evidence for effectiveness. Accountable Care. Providers are accountable and reimbursed for quality of care and clinical outcomes, not just volume of care.

19 Patients Treated: 4,155 As of 7/19/16 SITE Total Patients Treated CHCCW 594 Mat Su 382 Partnership 1308 Peninsula 652 Valley View 474 Bighorn 144 KANA 223 SWMCHC 378 TOTAL 4155

20 Depression Severity at Baseline Patient outcomes as of 5/1/16 Valley Cohort 1 Cohort 2 CHCCW Mat Su Partnership Peninsula Bighorn KANA SMCHC TOTAL View Sub total Sub total Baseline PHQ 9 score n=562 n=367 n=1247 n=575 n=442 n=3193 n=131 n=190 n=325 n=646 n=3839 None or Mild (0 to 9) 7% 13% 14% 7% 11% 11% 21% 27% 5% 18% 14% Moderate (10 to 14) 32% 26% 27% 27% 22% 27% 41% 32% 27% 34% 30% Moderately severe (15 to 19) 33% 31% 29% 33% 31% 31% 20% 29% 34% 28% 30% Severe (20 to 27) 28% 31% 31% 33% 36% 31% 18% 12% 33% 21% 26% Baseline PHQ 9 score (mean) % No PHQ 9 at Intake 7% 3% 5% 4% 1% 4% 14% 13% 4% 10% 7% Most recent PHQ 9 score n=560 n=367 n=1244 n=574 n=442 n=3187 n=129 n=190 n=324 n=643 n=3830 None or Mild (0 to 9) 49% 50% 42% 51% 48% 47% 63% 58% 42% 54% 40% Moderate (10 to 14) 22% 21% 24% 21% 22% 22% 20% 18% 23% 20% 21% Moderately severe (15 to 19) 18% 16% 18% 15% 17% 17% 12% 18% 17% 16% 17% Severe (20 to 27) 11% 13% 16% 14% 13% 14% 5% 6% 18% 10% 12% Most recent PHQ 9 score (mean) Average reduction in PHQ 9 from baseline to last/most recent Level of Depression at Intake among IMPACT Patients* 61% 63% 72% 63% 63% 64% 62% 73% 68% 68% 66% % 50% decrease or PHQ 9 <10* 47% 46% 36% 50% 45% 45% 50% 42% 41% 44% 45% % w/phq 9<5* 33% 32% 20% 25% 22% 26% 30% 29% 23% 27% 27% **Excludes patients with PHQ 9<10 at baseline

21 Depression Severity After Treatment Patient outcomes as of 5/1/16 Valley Cohort 1 Cohort 2 CHCCW Mat Su Partnership Peninsula Bighorn KANA SMCHC TOTAL View Sub total Sub total Baseline PHQ 9 score n=562 n=367 n=1247 n=575 n=442 n=3193 n=131 n=190 n=325 n=646 n=3839 None or Mild (0 to 9) 7% 13% 14% 7% 11% 11% 21% 27% 5% 18% 14% Moderate (10 to 14) 32% 26% 27% 27% 22% 27% 41% 32% 27% 34% 30% Moderately severe (15 to 19) 33% 31% 29% 33% 31% 31% 20% 29% 34% 28% 30% Severe (20 to 27) 28% 31% 31% 33% 36% 31% 18% 12% 33% 21% 26% Baseline PHQ 9 score (mean) % No PHQ 9 at Intake 7% 3% 5% 4% 1% 4% 14% 13% 4% 10% 7% Most recent PHQ 9 score n=560 n=367 n=1244 n=574 n=442 n=3187 n=129 n=190 n=324 n=643 n=3830 None or Mild (0 to 9) 49% 50% 42% 51% 48% 47% 63% 58% 42% 54% 40% Moderate (10 to 14) 22% 21% 24% 21% 22% 22% 20% 18% 23% 20% 21% Moderately severe (15 to 19) 18% 16% 18% 15% 17% 17% 12% 18% 17% 16% 17% Severe (20 to 27) 11% 13% 16% 14% 13% 14% 5% 6% 18% 10% 12% Most recent PHQ 9 score (mean) Average reduction in PHQ 9 from baseline to last/most recent Level of Depression at Intake among IMPACT Patients* 61% 63% 72% 63% 63% 64% 62% 73% 68% 68% 66% % 50% decrease or PHQ 9 <10* 47% 46% 36% 50% 45% 45% 50% 42% 41% 44% 45% % w/phq 9<5* 33% 32% 20% 25% 22% 26% 30% 29% 23% 27% 27% **Excludes patients with PHQ 9<10 at baseline

22 Response More than Double Usual Care Patient outcomes as of 5/1/16 Valley Cohort 1 Cohort 2 CHCCW Mat Su Partnership Peninsula Bighorn KANA SMCHC TOTAL View Sub total Sub total Baseline PHQ 9 score n=562 n=367 n=1247 n=575 n=442 n=3193 n=131 n=190 n=325 n=646 n=3839 None or Mild (0 to 9) 7% 13% 14% 7% 11% 11% 21% 27% 5% 18% 14% Moderate (10 to 14) 32% 26% 27% 27% 22% 27% 41% 32% 27% 34% 30% Moderately severe (15 to 19) 33% 31% 29% 33% 31% 31% 20% 29% 34% 28% 30% Severe (20 to 27) 28% 31% 31% 33% 36% 31% 18% 12% 33% 21% 26% Baseline PHQ 9 score (mean) % No PHQ 9 at Intake 7% 3% 5% 4% 1% 4% 14% 13% 4% 10% 7% Most recent PHQ 9 score n=560 n=367 n=1244 n=574 n=442 n=3187 n=129 n=190 n=324 n=643 n=3830 None or Mild (0 to 9) 49% 50% 42% 51% 48% 47% 63% 58% 42% 54% 40% Moderate (10 to 14) 22% 21% 24% 21% 22% 22% 20% 18% 23% 20% 21% Moderately severe (15 to 19) 18% 16% 18% 15% 17% 17% 12% 18% 17% 16% 17% Severe (20 to 27) 11% 13% 16% 14% 13% 14% 5% 6% 18% 10% 12% Most recent PHQ 9 score (mean) Average reduction in PHQ 9 from baseline to last/most recent Level of Depression at Intake among IMPACT Patients* 61% 63% 72% 63% 63% 64% 62% 73% 68% 68% 66% % 50% decrease or PHQ 9 <10* 47% 46% 36% 50% 45% 45% 50% 42% 41% 44% 45% % w/phq 9<5* 33% 32% 20% 25% 22% 26% 30% 29% 23% 27% 27% **Excludes patients with PHQ 9<10 at baseline

23 Remission Rate VERY Impressive 5 points higher than last year Patient outcomes as of 5/1/16 Valley Cohort 1 Cohort 2 CHCCW Mat Su Partnership Peninsula Bighorn KANA SMCHC TOTAL View Sub total Sub total Baseline PHQ 9 score n=562 n=367 n=1247 n=575 n=442 n=3193 n=131 n=190 n=325 n=646 n=3839 None or Mild (0 to 9) 7% 13% 14% 7% 11% 11% 21% 27% 5% 18% 14% Moderate (10 to 14) 32% 26% 27% 27% 22% 27% 41% 32% 27% 34% 30% Moderately severe (15 to 19) 33% 31% 29% 33% 31% 31% 20% 29% 34% 28% 30% Severe (20 to 27) 28% 31% 31% 33% 36% 31% 18% 12% 33% 21% 26% Baseline PHQ 9 score (mean) % No PHQ 9 at Intake 7% 3% 5% 4% 1% 4% 14% 13% 4% 10% 7% Most recent PHQ 9 score n=560 n=367 n=1244 n=574 n=442 n=3187 n=129 n=190 n=324 n=643 n=3830 None or Mild (0 to 9) 49% 50% 42% 51% 48% 47% 63% 58% 42% 54% 40% Moderate (10 to 14) 22% 21% 24% 21% 22% 22% 20% 18% 23% 20% 21% Moderately severe (15 to 19) 18% 16% 18% 15% 17% 17% 12% 18% 17% 16% 17% Severe (20 to 27) 11% 13% 16% 14% 13% 14% 5% 6% 18% 10% 12% Most recent PHQ 9 score (mean) Average reduction in PHQ 9 from baseline to last/most recent Level of Depression at Intake among IMPACT Patients* 61% 63% 72% 63% 63% 64% 62% 73% 68% 68% 66% % 50% decrease or PHQ 9 <10* 47% 46% 36% 50% 45% 45% 50% 42% 41% 44% 45% % w/phq 9<5* 33% 32% 20% 25% 22% 26% 30% 29% 23% 27% 27% **Excludes patients with PHQ 9<10 at baseline

24 Augmenting Collaborative Care Engagement Patient education In-app interventions Automated reminders for self-monitoring and medication taking Patient satisfaction Convenient patients can check in remotely at the time they prefer Secure and private communication Provider efficiency Less provider documentation (patients enter their own symptom scores) Fewer call attempts to reach patients Enhancing treatment-to-target Current information on patient status

25 Smartphone App Design Check In Outcomes Monitoring Progress Graph Scores Learn More Educational Content Call for Help Personalized Contacts Your Info Customizable Reminders, Content

26 Patient Generated Data integrated into Clinical Registry

27 CHCCW Pilot Patient Feedback The reminders were wonderful, had forgotten and when the reminder popped up, immediately took PHQ 9. [PHQ 9] took only a minute is discreet enough even if you were in a public setting. Great idea, especially for people who live far from a doctor.

28 SIF Evaluation Requirement CNCS requires evaluation as part of SIF Meeting intended outcomes and impacts Understanding how program is successful How program can be improved Building on lessons learned for future projects 28

29 Evaluation Purpose Understand Effect on Clinics Effect on Providers Effect on Patients Use information to help other rural clinics with implementation 29

30 Effect on Clinics Clinic experience implementing IMPACT Information about the organization (survey) Organizational information about their efforts to implement IMPACT (interview) Leadership surveys Pre Launch 18 months Post Launch Cohort 1 End of Grant Cohort 2 End of Grant (June 2017)

31 Effect on Providers Provider experience implementing IMPACT Primary care providers, psychiatric consultants, care managers, behavioral health providers, clinical supervisors and others Provider surveys 18 months Post Launch Survey Interview (optional)

32 Patient Demographics CHCCW Mat Su Partnership Peninsula Valley View Bighorn KANA SWMCHC All Organizations % n % n % n % n % n % n % n % n % n Total* Gender Women 72% % % % % % 83 68% % % 2607 Age group Men 28% % % % % % 48 32% 60 28% 92 32% 1218 <18 2% 10 1% 5 1% 13 2% 10 <1% 3 2% 3 12% 22 <1% 1 2% to 34 46% % % % % % 42 39% 74 38% % to 54 37% % % % % % 55 34% 65 36% % to 74 14% 80 21% 76 21% % 73 24% % 28 11% 21 19% 63 18% and older 1% 7 2% 8 1% 17 0% 0 % 3 2% 3 4% 8 6% 21 2% 67 Race American Indian / Alaska Native 1% 5 1% 5 3% 38 <1% 5 3% 12 48% 63 81% 153 3% 9 8% 290 Asian <1% 3 <1% 3 <1% 2 2% 11 <1% 3 0% 0 1% 2 0% 0 <1% 24 African American 2% 12 2% 7 <1% 6 3% 20 <1% 2 0% 0 1% 2 <1% 2 1% 51 Pacific Islander 0% 0 0% 0 <1% 6 2% 9 1% 4 0% 0 0% 0 <1% 1 <1 20 White 89% % % % % % 65 11% 22 91% % 3201 Mixed Race / Other 3% 14 <1% 1 <1% 9 3% 15 2% 7 0% 0 2% 3 <1% 2 1% 51 Unknown/Not reported 5% 29 5% 17 <1% 4 2% 9 12% 50 2% 3 4% 7 5% 14 4% 133 *Excludes patients without an initial PHQ 9

33 Effect on Patients Patient experience Symptoms, Quality of life, Economic well being Data Primary: Online care management registry (CMTS) Secondary: Clinic administrative data systems Secondary: Patient survey Cohort 1 & 2 33

34 Progress to Date: Economic Outcomes Clinic Administrative Data UDS data Cohort 1 complete Cohort 2 June 2017

35 Questions?

36 BREAK

37 Overcoming Common Challenges: Maintaining Caseload and Engagement Issues CHCCW KANA Bighorn

38 Overcoming Common Challenges: CHCCW Social Innovation Fund October 2016

39 Challenges Identified High turn over rates: providers, CMAs and dental assistants. Direct correlation with patients volume.

40 How Did We Know? Decrease in warm connections calls Drop in number of referrals Decrease in number of appointments Inconsistent screening Change in Care manager FTE, from 1.75 to 1.5 (October 2015)

41 Retention/Recruitment of Providers Recruitment to a rural place like Wyoming can be difficult. We definitely have shortages in the state, said Joe Steiner, dean of health sciences at the University of Wyoming. A lot of physicians are reaching retirement age. There s a pretty high demand for medical care across the state.

42 Recruitment Challenges in the Region The most often identified challenging position to recruit was Physician Family Practice without OB Clinical positions are much more difficult to fill than administrative positions The most often identified position with challenging turnover was Medical Assistant 2014 CHAMPS Region VIII Health Centers

43 Casper, Wyoming Industry Wyoming s economy is vulnerable to swings in commodities prices and global price competition. When the U.S. is doing well, Wyoming has more economic difficulties. Wyoming Department of Employment, Occupational Outlook 2010

44 Current Economic Environment Unemployment rates have increased with the decline in oil prices: statewide average in June was 5.7%, Natrona county 7.8%. Some individuals retained employment with a decrease in pay as high as 70%.

45 Weather Annual high temperature 59.2,low is 31.3 Average rainfall of inches Average snowfall of 75 inches We have the most wind in the US: average of 12.9 mph, but can reach 65 mph or higher.

46 The Challenge CHCCW s turn over rates between 2015 and 2016: 10 providers 8 dental assistants 20 Certified Medical Assistants OB/GYN department closed February 2016 Providers rotating between Quick Care and Family medicine Employees leaving town with spouses who lost jobs in the energy industry Employees leaving for other opportunities with higher pay/working multiple jobs to support families during difficult economic time

47 Turnover Last Day Job Title 1/2/ /25/ /31/ /30/ /9/ /18/ /27/ /11/ /30/ /8/201 5 Physicians Assistant Physicians Assistant Physician Physician Physician Nurse Practitioner Nurse Practitioner Nurse Practitioner Dentist Dentist

48 How the Challenge Looks in the Registry March 2015

49 Active Caseload 2015 April patients May June July August September PCP, NP left October 2015 November December IMPACT Champion PCP left OB/GYN left

50 Active Caseload 2016 January February 2016 March 2016 April 2016 May 2016 June July 2016 August 81 September OB/GYN department closed down 71 OB/GYN, CMO and PCP, NP left 71 RN Coordinator left 72 Hired MD, new CMO, Champion PCP 75 Hired NP, PCP

51 Addressing the Challenge Orientation to the IMPACT Model New Champion Provider Radke, MD (May 2016) New Primary Care Providers Quick Care Providers as PCPs Acclimating to the collaborative model Identifying schedule for consultation The cost benefit of collaborative care, 6:1 ratio Medical Assistants The importance of the MA role in identifying depression On going training Screening for depression is the 5th vital sign Communication with provider Not assuming the role of a mental health provider

52 Current Active Caseload

53 Discussion Is retention/recruitment a challenge in your clinic? What are some strategies you have used to minimize turn over?

54 IMPACT Challenges: Year 1 Kodiak Area Native Association SIF and John E Hartford Subgrantee Cohort 2 Year 2

55 Clinic Setting Kodiak Area Native Association is a non profit serving Alaska Natives, veterans and, since 2015, other community members in the Koniag region. KANA provides medical, dental, behavioral health and community services to citizens of Kodiak and the six rural communities on the island. In 2015, HRSA grant facilitated the opening of the new Mill Bay, which provides clinical services primarily to non Native patients. Total Patients at KANA 2789 Uninsured 45% Medicaid/Medicare 30% Commercial Insurance 25%

56 A Challenge We ve Identified Lower than expected enrollment numbers Anticipation that Mill Bay Clinic opening would increase enrollment. Monthly reports are not showing an increase. Today s Presentation Ongoing efforts to identify solutions Hypotheses moving forward Possible future solutions

57 How the Challenge Looks in the Registry SITE Care Mgr FTE Care Mgr Type Total Patients Treated Active Caseload Goal Minimum 1 Active Caseload 2 Contact >2months Active Caseload: % of Minimum 5+ Point Decrease 50%+ Decrease After at Least 10 Weeks Psychiatric Consultation 3 KANA June 2015 KANA Jan 2016 KANA April All in one % 46% 76% 83% 1 All in one % 36% 69% 69% 1.5 All in one % 47% 69% 63% Expectation that the opening of the Mill Bay clinic (October, 2015) would increase enrollment is not reflected in data. Note: data pulled from months when low enrollment could not be accredited to recent Care Manager turnover

58 Addressing the Challenge Hypothesis no.1: Low PHQ 9 completion rate: we aren t identifying clients in need of treatment. Solutions put into place: incorporate program information in to PHQ 9 so patients understand the purpose of the survey Remove patient name, use MRN to increase privacy Care managers will collect ALL PH 9s and count them against clinic visits to tabulate actual completion rate Re train front desk staff with script for delivering the PHQ 9 to patients

59 Data Obtained from PHQ 9 Collection May June July August Lost in the Workflow: Main 49% 61% 72% 65% Lost in the Workflow: MB 36% 45% 54% 52% These percents represent the proportion of PHQ 9s that don't get returned to the Care Manager. Reasons could include Patient leaves in waiting room, patient discardes, stuffed in pocket/bag, nurse doesn't get to review due to pressing medical issue, etc. Refused: Main 11% 15% 17% 20% Refused: MB 15% 15% 14% 20%

60 Addressing the Challenge cont. Hypothesis 2: Lack of collaborative approach Solution: Review workflow with front desk staff, ensure PHQ 9s are handed out every time. Ensure nurse staff gives patient PHQ 9 if is hasn t been completed in waiting room. Review language used by medical staff eliminate referral language and review team language

61 How it Looks Now in the Registry SITE Care Mgr FTE Care Mgr Type Total Patients Treated Active Caseload Goal Minimum 1 Active Caseload 2 Contact >2months Active Caseload: % of Minimum 5+ Point Decrease 50%+ Decrease After at Least 10 Weeks Psychiatric Consultation 3 KANA present 1.5 All in one % 42% 62% 65% Why no improvement? What we learned: While front desk staff and medical staff are all playing their part in the work flow, we have a high number of surveys that are not making it all the way through the workflow, and a number of clients declining to complete the survey which is limiting our new referrals. Hypotheses moving forward: 1. With a geographically limited population, do we have a limited number of people who will respond to our current approach 2. New cultural demographics added (military, Phillipino) means we have to explore cultural significance of reporting depression symptoms 3. Need to re examine program material may be too dense for patients

62 Continued Challenges, Questions, Concerns Work we plan to continue: Re examine IMPACT literature for maximum clarity and increased completion rates. Continue to hone teamwork efforts to unify all staff working on patients team. Work we plan to start: Take a deeper look at cultural and practical barriers that may be preventing patients from filling out the PHQ 9 and determine resolutions.

63 Discussion Interested in other clinics experience/success using PHQ 2 vs PHQ 9 Interested in other clinics experience with patients declining to fill out the PHQ 9 and solutions

64 Overcoming Common Challenges Social Innovation Fund October 2016

65 Clinic Setting Located In: Ashland, Montana Hardin, Montana Clinic serves 70% BVHC patients are Tribal Members 10% BVHC patients are 65 years and over 13% BVHC patients on Medicaid

66 Program Specifics 1 full time care manager/therapist 1 psych consultant 6 full time Primary Care Providers 3 part time Primary Care Providers

67 A Challenge We ve Identified Low Retention rates of patients IMACT program not reaching goal of minimum active case load Losing pt. in the IMACT program process Majority of pt. with high PHQ 9 also have chronic pain as chief complaint and were not returning to address depression symptoms

68 How it Looked in the Registry SITE Care Mgr FTE Care Mgr Type Total Patients Treated Active Caseload Goal Minimum 1 September 2015 Active Caseload 2 Contact >2months Active Caseload: % of Minimum 5+ Point Decrease 50%+ Decrease After at Least 10 Weeks Psychiatric Consultation 3 Bighorn 0.5 Shared % 64% 89% 88%

69 Addressing the Challenge Failures Wait for pt. to contact us after missing apt. Mail reminders Have only one contact phone number

70 Addressing the Challenge Successes Combined Care manger and Therapist one full time position Get everyone on board of understanding program Competition with PCP to see their referral stats Meet with team to identify trends (Chronic Pain and Depression) Large number of chronic pain patents not returning but the care manger gives the pt. their script after meeting with them. This has improved treatment outcomes!

71 How it Looks Now in the Registry

72 Chronic Pain and Depression in Registry Patient 1 Patient 2 DATE OF CONTACT CONTACT TYPE WEEKS IN TX PHQ- 9 DATE OF CONTACT CONTACT TYPE WEEKS IN TX PHQ- 9 12/2/2015 Initial Visit /31/2015 Psychiatric Consultation Note 4 1/11/2016 Follow Up /20/2016 Follow Up /25/2016 Psychiatric Consultation Note 7 2/29/2016 Follow Up /17/2016 Follow Up /25/2016 Follow Up /25/2016 Psychiatric Consultation Note 20 5/10/2016 Follow Up 22 5/17/2016 Follow Up /24/2016 Follow Up /14/2016 Follow Up /10/2015 Initial Visit /30/2015 Follow Up /7/2015 Follow Up /21/2015 Follow Up /31/2015 Psychiatric Consultation Note 7 1/4/2016 Follow Up /26/2016 Follow Up /2/2016 Follow Up /14/2016 Psychiatric Consultation Note 17 3/22/2016 Follow Up /20/2016 Follow Up 23 5/12/2016 Relapse Prevention Plan /7/2016 Discharge 30 6/15/2016 Relapse Prevention Plan 28 1

73 Chronic Pain and Depression in Registry Patient 3 Patient 4 Date of Contact Type Contact DATE OF CONTACT CONTACT TYPE WEEKS IN TX PHQ-9 7/31/2015 Initial Visit 0 9 8/6/2015 Follow Up 0 8 9/10/2015 Follow Up /19/2015 Follow Up /30/2015 Psychiatric Consultation Note 13 11/2/2015 Psychiatric Consultation Note 13 11/13/2015 Follow Up /20/2015 Follow Up /14/2015 Psychiatric Consultation Note 19 12/14/2015 Psychiatric Consultation Note 19 12/15/2015 Follow Up /22/2015 Follow Up /31/2015 Follow Up 21 1/20/2016 Follow Up /25/2016 Psychiatric Consultation Note 25 2/3/2016 Follow Up /17/2016 Follow Up /22/2016 Psychiatric Consultation Note 29 2/24/2016 Follow Up /23/2016 Follow Up 33 4/20/2016 Relapse Prevention Plan /11/2016 Follow Up /7/2016 Discharge 44 Weeks in Tx 6/4/2015 Initial Visit /25/2015 Psychiatric Consultation Note 3 10/20/2015 Follow Up /20/2015 Psychiatric Consultation Note 19 11/6/2015 Follow Up /9/2015 Follow Up 22 11/30/2015 Follow Up 25 12/4/2015 Follow Up /14/2015 Psychiatric Consultation Note 27 1/26/2016 Follow Up /22/2016 Psychiatric Consultation Note 37 2/29/2016 Follow Up /7/2016 Follow Up 39 3/15/2016 Follow Up /22/2016 Follow Up /5/2016 Follow Up /20/2016 Follow Up /2/2016 Psychiatric Consultation Note 47 6/7/2016 Relapse Prevention Plan /7/2016 Follow Up /28/2016 Discharge 60 PHQ 9

74 Continued Challenges, Questions, Concerns High Nomadic Population Chronic pain Depression or pill seeking? Poverty Phone coverage Internet access Mail Dispersed Population No Public Transportation Family Dynamics

75 Continue to Improve Continue to look at trends Continue to be flexible and make changes accordingly Continue to communicate with team and pt. to strive for improvement

76 Overcoming Common Challenges: Maintaining the Model of Care Issues SWMCHC Peninsula Partnership

77 Overcoming Common Challenges Social Innovation Fund October 2016

78 Clinic Setting Organization FQHC established 1986 Serves approximately 13,000 unique patients/yr Locations Butte, MT Dillon, MT Sheridan, MT (Pharmacy) Patients (2015 # s) 24% Medicaid 13% Medicare 31% Uninsured 32% Private Insurance (Increase ACA) Depression/Mood disorder Visits (2015) 5,742 Depression is the highest diagnosis in our clinic, close to half of all patients we see

79 A Challenge We ve Identified Reluctance to discharge patients with 2 months of no contact High need patients that we want to track but have not been able to successfully contact Many contacts attempts are made, but for a variety of reasons, we are unable to have that positive contact Due to busy schedules, multiple responsibilities, wanting to track patients this occasionally does not happen

80 How the Challenge Looks in the Registry

81 Addressing the Challenge Our Shared Care Managers have worked hard to manage their caseloads Implemented policy of 30 days and 3 contact attempts At 30 days from first contact attempt, if we are unable to contact the patient, then we will discharge them from IMPACT Always willing to re admit them into IMPACT

82 How it Looks Now in the Registry

83 Continued Challenges, Questions, Concerns Staff turnover Burnout

84 Discussion

85 Overcoming Common Challenges Peninsula Community Health Services October 2016

86 Clinic Setting PCHS opened its doors in 1987 In 1988 we had 11 staff Serving over 2,211 patients 87% of patients had a household income of less than $1,000 a month In 1993 became FQHC Fast forward to 2015: Nearly 200 staff Serving over 24,000 patients

87 A Challenge We ve Identified Maintaining a more even distribution of 2 contacts per month 1 via in person 1 via phone Phone contacts are difficult due to: Transient nature of patients Patients with limited phone minutes Time for Care Manager to make calls

88 How the Challenge Looks in the Registry

89 Addressing the Challenge Hired administrative staff to assist with other BH programs to free up Care Manager time Focus on schedule optimization Designated admin time for phone contacts

90 How it Looks Now in the Registry

91 Continued Challenges, Questions, Concerns Inaccurate contact numbers Challenge with connecting with patients in timely manner Access issues Continue scheduling optimization Consider expanding roles and responsibilities of non clinical staff to assist with contacts

92 Discussion How are you, as Care Managers, able to complete 2 contacts per month with one via in person and one via phone?

93 Overcoming Common Challenges: Partnership Social Innovation Fund October 2016

94 Partnership Health Center

95 Clinic Setting Location Missoula, MT Organization Established in 1989 FQHC established in ,092 unique patients in ,395 unique patients in 2015 Patients in 2012: 62% Self pay 19% Medicare 11% Medicaid 9% Private Pay Patients in 2015: 39% Self pay 14% Medicare 20% Medicaid 27% Private Pay

96 A Challenge We ve Identified PHQ9 completion rates lower in Behavioral Health compared to the medical clinic. Medical clinic completion rate 76.1% in Tracked using the depression screening UDS measure.

97 How the Challenge Looks in the Registry Completion of PHQ9 with Patients

98 Addressing the Current Challenge Discussing in staff meetings how care managers and therapists introduce the PHQ9 to patients. Identifying successful strategies for completing PHQ9 during follow up calls. Ex.: mailing patient a copy of the PHQ9.

99 How it Looks Now in the Registry

100 Continued Challenges, Questions, Concerns Continued Challenge Decreasing completion rates of PHQ9. Trying to identify what changed between the spring to now. Was the previous workflow more effective?

101 Discussion Have other clinics set goals for PHQ9 completion? Strategies used to engage patient in completing PHQ9 when they express screener burnout.

102 LUNCH