Clinical Elements of Integration Jeff Capobianco Director of Practice Improvement National Council for Behavioral Health Pam Pietruszewski Integrated Health Consultant National Council for Behavioral Health Overview Health Conditions/Concerns Evidencebased & Best Practice Approaches Clinical Pathways Workflow Essential Skills for Integrated Care Teams 1
Diabetes Depression Cardiovascular Disease Obesity Health Conditions Substance Abuse/Dependence (including Tobacco) Chronic Obstructive Pulmonary Disease Medication Adherence Weight Management Chronic Pain Management Smoking Cessation Insomnia / Sleep Hygiene Psychosocial and Behavioral Aspects of Chronic Disease Any Health Behavior Change Health Concerns 2
Evidence-Based Practices Define how best to clinically respond to disease The disease state itself can be measured Then must be embedded in a clinical pathway IMPACT Model Evidence-Based & Best Practices for Integrated Care Screening Brief Intervention & Referral to Treatment (SBIRT) Motivational Interviewing Wellness Assessment Brief Solution Focused Therapy Trauma Informed Care 3
Darren Health Conditions & Evidence Based Practices Clinical Pathways The Framework Screening Assessment Treatment Monitoring Follow-up 4
Necessary Clinical Pathways Treatment of: Depression Anxiety Trauma Psychosis/Thought Disorder Substance Addiction/ Abuse Clinical Pathway Core Components Policy Training Protocol Standing Orders Staff Cheat Sheets Process Monitoring Continuous Quality Improvement Celebrating Successes Embracing Opportunities for Improvement 5
Workflow All clinic workflows are indirectly built upon the disease pathway the way disease manifests and is treated in the healthcare clinic Clinic Workflow Processes Each workflow is unique to that clinic and team Workflows include clinical and administrative processes Clinic location, population served, staffing, building layout/architecture, and resources (e.g., equipment and staffing levels) all effect the workflow process 6
Clinic Workflow Processes The clinic s team-based approach (or lack thereof) and use of data to inform the workflow process is the primary driver as to how well the clinic is able to deliver care to evidence/best practice fidelity (or not ) and be financially viable Darren Arrives Front desk ready with forms Lobby has signs & brochures about whole-health care All care team members pictures on display 7
Example Screening Flow Front Desk: Receptionist Triage Room: Care Manager/Medical Assistant Exam Room: PCP Administers brief healthy lifestyle screening Your doctor would like you to fill this out Reviews brief screens Administers condition specific screens if positives Uses MI skills to provide support, education, goal setting Reviews screen results Conducts clinical assessment Makes diagnosis Makes warm handoff to team member(s) for follow-up 14 Warm Hand Off for Coordination of Care Who? Care manager, social worker, psych intern Logistics? Where do they sit, how are they notified, scheduling 8
Variation = Waste = Poor Care The degree to which a clinic can standardize clinical and admin. processes to reduce variation/waste will determine the quality of financial sustainability and care provision Measuring processes and resulting outcomes is the only way to determine if a process is efficient and effective (or variable and wasteful) Unpacking the Clinic Workflow Diseases have distinct stages that include pre-onset, onset, and recovery/maintenance states depending on the condition The health care system is designed to respond to each stage of the disease pathway and captures signs/symptoms metrics to diagnosis conditions Many argue the current healthcare system addresses the acute illness state well but not the prevention, onset, and recovery/maintenance stages 9
Darren Clinical Pathways & Workflows The Team as an Emerging Standard of Care The high-performing team is now widely recognized as an essential tool for constructing a more patient-centered, coordinated, and effective health care delivery system. Source: Mitchell, P., M. Wynia, R. Golden, B. McNellis, S. Okun, C.E. Webb, V. Rohrbach, & I. Von Kohorn. (2012). Core principles & values of effective team-based health care. Discussion Paper, Institute of Medicine, Washington, DC. www.iom.edu/tbc. P.5. 10
Essential Skills Leadership Engagement Screening/assessment Diagnosing Billing/coding Treatment planning Patient & family education/health literacy Health informatics Using data to inform care Supervision/team building/maintenance 11
Receptionist Care Coordinator Social Worker Darren Physician Psychiatrist Pharmacist Population Health Case Review Everyone looking at same information Rotating scribe All new cases All those not improving 12
Treating to Target Example for Population Health Patient Primary Physician Diagnosis Initial Contact Date Initial PHQ-9 Self-mgmt goal Follow-up Contact Date Followup PHQ-9 Claus, S. Hernandez 296.21 12/19/10 12 Eat only 2 cookies/wk 4/26/11 13 Poppins, M. Williams 296.31 1/28/10 10 Find backup babysitter 1x/wk 2/28/10 4 Potter, H. Crane 300.4 4/30/10 20 Relaxation techniques 4x/wk 5/17/10 17 Montana, H. Williams 300.4 2/21/10 16 Write in journal daily 4/1/10 22 Vader, D. Williams 296.21 3/18/10 26 Call son to set lunch date 3/30/10 26 Mouse, M. Hernandez 296.21 4/2/10 11 Walk dog 4/14/10 8 13
Situation Background Assessment Recommendation 26 Measurable Clinical Outcomes Cardiovascular: Blood Pressure, Lipid levels Obesity: BMI Pain: Brief Pain Inventory Depression: PHQ-9 Anxiety: GAD-7 Tobacco Use: Breath CO Diabetes: Hemoglobin A1c Alcohol/Drug Use: AUDIT, DAST, CRAFFT 14
Other Outcome Measures Patient Activation Patient Satisfaction Functioning: DLA-20 No show rates Rx fills ER visits Hospital admissions/readmissions Darren s follow-up Every touch point = opportunity 15
Darren Team Members & Clinical Outcomes Efficient & Effective Integrated Clinic Measurement How consistently/reliably admin/clinical protocols are followed (e.g., MAO s capture PHQ screens)? How consistently/reliably Rx ers Dx/respond to clinical findings? How well the team is able to aggregate and conduct population health analyses to determine overall impact of clinic processes/care? The morale of the team (i.e., stress level, communication, and leadership). 16
Measuring the Components Team-base care approach + Standardized clinical processes + Standardized administrative processes Actionable information in form of Clinical & Financial Outcome Metrics If you are not measuring a process you don t know what you are doing. If you are not measuring processes you can t improve. If you are not measuring processes you are operating blindly and therefore at risk. Effective Elements of Supervision 1. Establish Individual Work Plan Benchmarks 2. Set Individual & Team Goals 3. Drive Interdisciplinary Training 4. Understand Staff Person s Orientation 5. Care for the Caregiver 6. Continuous Bi-directional Evaluation/Feedback Sources: Michelle Kipick Cawn Inter-professional Mentoring Guide, by Deutschlander & Suter, Alberta Health Services 17
Connecting 4 Core Competencies 1. Interpersonal Communication 2. Collaboration & Teamwork 3. Care Planning & Coordination 4. Practice-Based Learning and Quality Improvement http://www.integration.samhsa.gov/workforce/core-competencies-forintegrated-care 1. Interpersonal Communication Patients, family members and staff Quick and effective rapport Active listening (open-ended inquiry, reflections, etc) Health literacy and teach back Preferences and adaptations 18
2. Collaboration & Teamwork Interdisciplinary team Culture, trust Clarity of roles/tasks Huddles Handoffs Shared-decision making 3. Care Planning & Coordination Integrated care plans Linked services Information exchange Warm handoffs Prioritized treatment goals Type & intensity of services matched to needs 19
4. Practice-Based Learning and Quality Improvement Workflows, small tests of change Process and outcome metrics Billing Embedded changes into policies & procedures Sustainability Connecting the Clinical Elements of Integration Health Conditions/Concerns Evidencebased & Best Practice Approaches Clinical Pathways Workflow Essential Skills for Integrated Care Teams 20
Discussion! Thank You! Pam Pietruszewski pamp@thenationalcouncil.org Jeff Capobianco jeffc@thenationalcouncil.org 21