IMPLEMENTATION OF INTEGRATED CARE FROM A LEADERSHIP PERSPECTIVE. Tennessee Primary Care Association Annual Conference October 25 26, 2012.

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1 IMPLEMENTATION OF INTEGRATED CARE FROM A LEADERSHIP PERSPECTIVE Tennessee Primary Care Association Annual Conference October 25 26, 2012 Outline I. Brief Overview of Cherokee (Who are we?) II. The Integrated Care Model (Why IC and what is it?) III. Integrated Care Operations (How to do it and how not to do it?) Copyright Cherokee Health Systems,

2 10/16/2012 I. Overview of Cherokee Health Systems Our Mission To improve the quality of life for our patients through the integration of primary care, behavioral health and substance abuse treatment and prevention programs. Together Enhancing Life Copyright Cherokee Health Systems,

Merging the Missions of CMHC s and FQHC s

1960 Chartered as Morristown Mental Health

Health Systems 2002 Cherokee s Initial FQHC

Migrant/Farm Worker Health Center 2008 Homeless

3 Merging the Missions of CMHC s and FQHC s Cherokee Health Systems Epochs of Development 1960 Chartered as Morristown Mental Health Center 1984 Clinch Mountain Regional Health Center, Inc Union Grainger Primary Care 1993 Cherokee Health Systems 2002 Cherokee s Initial FQHC grant 2005 Corporate Consolidation 2006 Migrant/Farm Worker Health Center 2008 Homeless Health Center 2011 Behaviorally Enhanced Patient Centered Medical Home Copyright Cherokee Health Systems,

4 Cherokee Health Systems FY 2011 Services 43 Clinical Locations in 12 East Tennessee Counties Number of Patients: 60,896 unduplicated individuals New Patients: 19,573 Patient Services: 475,628 Cherokee Health Systems Number of Employees: 610 Provider Staff: Psychologists 44 Master s level Clinicians 64 Case Managers 32 Primary Care Physicians 24 Psychiatrists 10 Pharmacists 9 NP/PA (Primary Care) 26 NP (Psych) 12 Dentists 2 Copyright Cherokee Health Systems,

5 Strategic Emphases Integration of Behavioral Health and Primary Care Outreach to Underserved Populations Training Health Care Providers School Based Health Services Tele health Applications Safety Net Preservation II. The Integrated Care Model Copyright Cherokee Health Systems,

6 Copyright Cherokee Health Systems,

7 The Case for Integration of Safety Net Providers Expands the Primary Care service model to address the most common presenting complaints Addresses the most pressing concerns of the CMHCs access, health status of SMIs and survival In Quest of Integration Copyright Cherokee Health Systems,

8 Integrated Care Integrated Care is the process and product of medical and mental health professionals working collaboratively and coherently toward optimizing patient health through bio psychosocial modes of prevention and intervention. O Donohue, Byrd, Cummings, and Henderson (2004) Integrated Care Goals Improved recognition of BH needs Improved communication and co management Increased availability of BH expertise Meet patients where they show up Prevention, at risk Intervention, intervention Triage and coordination with specialty BH Copyright Cherokee Health Systems,

Cherokee s Blended Behavioral Health and Primary Care Clinical Model Embedded Behavioral Health Consultant on the Primary Care Team Real time behavioral and psychiatric consultation available to PCP

9 Cherokee s Blended Behavioral Health and Primary Care Clinical Model Embedded Behavioral Health Consultant on the Primary Care 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 Healthcare Home The Behavioral Health Consultant (BHC) in Primary Care Management of psychosocial aspects of chronic and acute diseases Application of behavioral principles to address lifestyle and health risk issues Emphasis on prevention and self help approaches, partnering with patients in a treatment approach that builds resiliency and encourages personal responsibility for health Consultation and co management in the treatment of mental disorders and psychosocial issues Copyright Cherokee Health Systems,

10 Typical BHC Services in Primary Care Triage/Liaison Behavioral Health Consultation Behavioral Health Follow Up Adherence Enhancement Relapse Prevention Behavioral Medicine Consultative Co Management Group based interventions Conjoint Consultation On Demand Medication Consultation Care Management Psychiatric Consultation PCP Consultation School/Agency Consultation Prevention Telephone Consultation PCP Referrals for Behavioral Health Consultation Services Diagnostic clarification and intervention planning Facilitate consultation with psychiatry regarding psychotropic medications Behavior and mood management Suicidal/homicidal risk assessment Substance abuse assessment and intervention Panic/Anxiety management Interim check of psychotropic medication response Co management of somaticizing patients Parenting skills Stress and anger management Copyright Cherokee Health Systems,

11 PCP Referral for Behavioral Health Consultation Services HEALTH BEHAVIOR / DISEASE MANAGEMENT Medication Adherence Weight Management Chronic Pain Management Smoking Cessation Insomnia / Sleep Hygiene Psychosocial and Behavioral Aspects of Chronic Disease Any Health Behavior Change Management of High Medical Utilization Integrated Care Integration vs. Co Location Co Located Mental Health Embedded member of primary care team Patient contact via hand off Verbal communication predominate Brief, aperiodic interventions Flexible schedule Generalist orientation Behavior medicine scope Ancillary service provider Patient contact via referral Written communication predominate Regular schedule of sessions Fixed schedule Specialty orientation Psychiatric disorders scope Copyright Cherokee Health Systems,

Treatment Team Meetings Telepsychiatry Co Management of Care

12 The Integrated Care Psychiatrist Access and Population Based Care Consultation Enhance the Skills of Primary Care Colleagues Treatment Team Meetings Telepsychiatry Co Management of Care Telepsychiatry Consultation Copyright Cherokee Health Systems,

13 Communication Model Face to Face Verbal Feedback Electronic Health Record/Tablets Treatment Team Telehealth Consultation/Telephone Copyright Cherokee Health Systems,

14 III. Integrated Care Operations Planning Build Integrated Care into your Strategic Plan 3 5 year plan Keep the end in mind Establish goals, objectives and action steps to achieve the end Involved key staff, Board as appropriate Develop annual tactical plans Build around goals, objectives and action steps from the Strategic Plan Adjust as needed Copyright Cherokee Health Systems,

15 Culture Mission Patient centered Clinical drivers Innovation Risk taking Fast, Imperfect Implementation ( Ready Fire Aim ) Plan Do Study Act (PDSA) No sandboxes Persistence Staffing Get the right people on the bus, and the wrong people off the bus Right people Committed to excellence clinical and operational Embrace change See the big picture Attentive to details Flexible/willing to try new ideas Fit the integrated care culture Computer literate Wrong people Resistant to change Mercenary Negative My turf Copyright Cherokee Health Systems,

16 Staffing (cont) The Integrated Care Clinical Team 3 Primary Care Providers 1 Behavioral Health Consultant Specialty Mental Health (LCSWs, PhDs) Psychiatry (real time and referrals to and from) Direct Medical Support (nursing) (2.0 per FT PCP) Direct Administrative Support (front desk, office managers, etc.) 1.25 X +.75Y = Number of Administrative Support X = PCP FTEs Y = Behavioral FTEs Staffing (cont) Training Skills are essential: Train all staff in integrated care: Overview of the Integrate Care Model Benefits of Integrated Care Challenges of Integrated Care Their Role and Responsibilities in Integrated Care Interviews, orientation, OJT In person, web based, employee newsletter, etc. Front desk people are absolutely key. One of the most challenging positions in the whole organization. Office Manager is key. Copyright Cherokee Health Systems,

17 BEHAVIORAL CONSULTATION CODING Behaviorist with Patient Primary Focus of Clinical Attention Medical Assessment or Intervention? Evaluation (90801) Behavioral Therapeutic or Evaluative? Initial Assessment Individual Individual (20 30 min) Diagnostic Interview Re Assessment Group (2 or more) Family (with patient) Family (w/o patient) NOTE: Primary Diagnosis must match the CPT code selected. Facilities and Layout We use three (3) exam rooms per PCP Embed one (1) BHC office between (or close to) the PCP exam rooms Create a close physical environment between PCPs and BHCs Avoid BHC end of hallway, closed door situations Nursing station and triage close to BHCs Confidential spaces available for quick, hallway consultations Copyright Cherokee Health Systems,

confidential patient spaces) Little things matter (locations of phones,

18 Facilities and Layout (cont) Study patient flow carefully From check in to check out Lean design (moving patients or moving services, paperwork, confidential patient spaces) Little things matter (locations of phones, copiers, printers, wireless, etc.) Copyright Cherokee Health Systems,

19 Electronic Health Records Difficult to do Integrated Care with paper charts Electronic charts allow sharing of records simultaneously by multiple providers Integrated charts Security levels for behavioral health Free text vs. data fields Reporting We use UDS comparisons for FQHCs whenever possible. Peer comparisons. Productivity measures include: Medical Team Productivity Physician Productivity NP Productivity BHC Productivity Specialty behavioral productivity Psychiatry productivity Copyright Cherokee Health Systems,

20 Reporting (cont) Cherokee Score Cards. We measure: Patient Satisfaction (NPS 1 10 scale). Goal of 8 or higher. Quality (BMI, Depression, Tobacco). Goals vary. Efficiency (Cost per visit). Goals vary by medical and BH. Each goal met = $100 per quarter x 3 goals = $300/Qtr Up to $1,200 bonus per year Monthly feedback at staff meetings and posted on intranet Distributed to each Team member equally Leadership Challenges Staffing and Recruiting Scheduling (largest driver of satisfaction, productivity, quality and financial results) PCPs 15 min. established/30 min. new BHCs 15 min/ 30 min. Scheduled during off peak hours and scheduled before PCP visit. Open during peak hours. Specialty BH 30 min. and 45 min. Provider choice. Psychiatry 15 min. established/30 min. new Copyright Cherokee Health Systems,

21 Leadership (cont) Full time provider productivity expectations: 100+ primary care physician encounters/week 70+ primary care NP encounters/week 60+ BHC encounters/ week 35+ behavioral specialty encounters/week 90+ psychiatry provider encounters/week Leadership (cont) Assuring access to care when patients need it No wrong door medical or behavioral Over 19,000 new patients last year Pressure on providers and schedulers Challenge balancing new and established patients Approximately 50% medical and 50% behavioral Patient Centered Medical Home IC fits naturally with PCMH Copyright Cherokee Health Systems,

22 Leadership (cont) Communications 600+ employees across multiple clinics and multiple counties Flat organizational chart The Update, s, phone, intranet, web, etc. Getting everyone on board Board, providers, support staff, patients Paper Paper records come in from specialists, ERs, labs, diagnostic centers, inpatient daily Need to feed the EHR scanning is a challenge volume and accuracy Hoping for a Health Information Exchanges (HIE) in 2013 Leadership (cont) Pharmacy Affordable drugs (340B (in house and contract), Pharmacy Assistance Programs, charitable contributions) Referral Arrangements OB/GYN, hospitalists, specialists (GI, cardiology, ortho) Negotiating global payment arrangements Many payers focus only on fee for service payments; miss the bigger picture of total costs in the system (ER, inpatient, specialists, etc.) Copyright Cherokee Health Systems,

23 Funding Mechanisms Shift from volume based to value based funding Fee For Service Case Rate Capitation Blended Capitation Incentive Pools / Shared Savings Percent of Premium Pay for Performance Leadership (cont) Measuring Clinical Outcomes Diabetes, Depression, Obesity, etc. You re not managing it if you re not measuring it Measuring Economic Outcomes Practitioner Productivity, ER Visits, Pharmaceutical Costs, Psych/Med Surg Hospitalizations Measuring Satisfaction Practitioners, Patients, Referral Sources Copyright Cherokee Health Systems,

24 Questions Copyright Cherokee Health Systems,

Blending Behavioral Health and Primary Care. Cherokee Health Systems Clinical Model

Blending Behavioral Health and Primary Care Cherokee Health Systems Clinical Model Brittany Tenbarge, Ph.D. Behavioral Health Consultant Licensed Clinical Psychologist Our Mission To improve the quality