The Health Integration Collaborative A Year in the Making Mary Jo Whitfield, VP of Behavioral Health Cheri DeBree, Director of Integrated Health
Presentation Objectives An overall look at integrated health practice A clinical/operational look at JFCS s Integrated Health Program as a possible model for integrative care. A practical look at how our electronic health record, NextGen, assists us throughout our program from beginning to end of a client s services with us. How reports generated from our electronic health record has allowed us to manage our program and helped us capture outcomes data.
Why Integrate Physical and Behavioral Health Care? Behavioral and physical health care have historically operated in silos. Health care integration is designed to: Improve patient access to care in a setting where patients are most comfortable. Reduce health care disparities. Contain costs by promoting a whole health approach. Improve patient outcomes through coordination of care.
Key Drivers of Integrated Health Patient Protection and Affordable Care Act State Health Insurance Exchanges Mental Health Parity Medicaid Expansion Maricopa County Regional Behavioral Health Authority Contract
National Driver: Affordable Care Act Health Insurance Exchanges Mental Health Parity Medicaid Expansion
Concepts Common to All Integrated Care Models Medical or Health Home Health Care Team Stepped Care Four Quadrant Clinical Integration
Four Quadrant Clinical Integration
Models of Integrated Care Coordinated Care Co-Located Care Transformed/Full Integration Virtual Integration
Jewish Family and Children s Services Who are we? Outpatient Behavioral Health Provider - Maricopa County In operation since 1935 JFCS is Currently serving 5,025 adults and 4,838 children and has about 90% Medicaid client population Our enrollment reflects the cultural diversity of our county Magellan Behavioral Health of Arizona Community Re-investment Grant
Integrated Health Program Data Program began May 1, 2012 1,400 clients served 700 active clients in the program typically 2,400 Health Risk Assessments have been collected 60% opt in rate as new clients to JFCS
Integrated Health Program Data Collaborative relationship with MIHS since August, 2010 Partnered with MIHS, a federally qualified Health center look alike 4 clinics across Maricopa County 8 Health Navigators
Integrated Health Client Demographics Women 80% Men 20% Age Demographics 60 + = 5% 50-59 = 18% 18-29 = 24% 40-49 = 24% 30-39 = 29% Age 18-29 Ages 30-39 Ages 40-49 Ages 50-59 Ages 60 +
Axis I Diagnosis Analysis
Axis III Medical Conditions Analysis
Chronic Disease Representation in the Integrated Health Client Population
With being overweight or obese being one of the lead health concerns with our clients, nutrition is discussed as part of our program.
Community Re-Investment Grant Objectives Objective 1: Assist behavioral health recipients in establishing/maintaining an ongoing, lasting relationship with a primary care provider. Objective 2: Facilitate improvements in the physical health of behavioral health recipients. Objective 3: Improve the mental health of behavioral health recipients. Objective 4: Enable behavioral health recipients to increase control over their health. Objective 5: Develop a health information infrastructure that includes an electronic medical record and shared health information for behavioral health recipients and their primary care and behavioral health providers.
Objective 1: PCP Relationship Investigate clients current relationship with Primary Care Physician (PCP) Is client is satisfied with current PCP Is client with Maricopa Integrated Health System already Assist client in changing PCP with AHCCCS PCP Notification auto faxed from EHR Assist client in scheduling first appointment with MIHS
Objective 2: Improved Physical Health Clients recent medical visits Client s satisfaction with current PCP Maricopa Integrated Health Systems Preventive screenings and testing Appointment planning Transportation to appointments if needed Compiling of medical records Medical decision making Advocate for the client Chronic Disease Self Management Stanford Best Practice Improved coordination and collaboration between medical and behavioral health through HIE and other efforts
Objective 3: Improved Mental Health People with mental health and substance use disorders die 25 years younger than the general population on average, according to a 2008 study done by the National Association of State Mental Health Program Directors (NASMHPD) In Arizona, the average is even higher at 32 years earlier
Client Quote on Integrated Care Services I have been a patient at JFCS for several years now and have received exceptional care. My life has improved since I first came here and I am grateful. However, since I was first introduced to Integrated Health by my peer navigator, the care I receive has become much more meaningful. Not just the behavioral health care, the physical health care I receive has improved as well. I say this because Adrienne has enlightened me to the fact that physical and emotional well being are inter-connected and cannot improve if either is neglected. - Anonymous satisfaction survey comment
Objective 4: Increased Control in Overall Health Teaching self management skills Decision making skills Health literacy skills equips clients to improved ability to manage health Empowerment skills Nutrition and exercise Information Resources Social Supports Chronic Disease Self Management WHAM
CDSMP Health Living Quotes from Clients After going to the CDSMP class, I learned a lot about how to take care of myself. I learned that I am not alone and that others suffer from similar health problems as me. I used to feel alone, but now I know I am not. - RS, CDSMP work shop participant I learned so much in the CDSMP class. People always stated that I was too young to be sick all the time and I felt ashamed about it. Now I realize that bad things happen to good people and I realize I can t compare myself to others. Just take care of myself so I can take care of my family. - BB, CDSMP work shop participant
Health Literacy is an important component of the IH Program
Relaxation and Stress Management Classes Quote from a enrolled client: The relaxation class helps me to cope with my problems better and helps me think in a more positive way. I really enjoy coming and being a part of this two days a week. I feel like it is empowering me, making me stronger as a person, more positive, and healthier in my lifestyle. This is a wonderful program. Nearly 60-90% of visits to healthcare professionals are either caused or exacerbated by stress. Dr. Herbert Benson: Institute of Mind-Body Medicine at Massachusetts General Hospital - SF, Integrated Health Client One of the most important components of human resiliency is social support. There is a lot of data supporting the importance of social supports in health outcomes.
The Relaxation Response Research shows the Relaxation Response is an essential resiliency self-management skill that is as predictable as medication in immediately reversing the stress-induced flight-or-fight response. -Benson, H. The Relaxation Response, William Morton and Company, 1975 Let s Do It!
EMPOWERING CLIENTS Helping clients gain the knowledge, skills, and attitudes for coping with changes in lifestyle and circumstances Learning to help themselves, management of their own care Greater confidence in themselves Increases clients understanding of the medical system Greater ability for the client to meet their own needs Gives clients knowledge that they can share with others
EMPOWERING CLIENTS Working our way out of a job from day one Encouraging ability to self care, cope and use active communication skills Enhancing ability to be assertive Providing access to information and resources Discussing various options and helping with decision-making process
Objective 5: Shared Health Information Continuity of Care Document: A patient summary containing a core data set of the most relevant administrative, demographic, and clinical information facts about a patient's healthcare, covering one or more healthcare encounters. It provides a means for one healthcare practitioner, system, or setting to aggregate all of the pertinent data about a patient and forward it to another practitioner, system, or setting to support the continuity of care. Six Mandated CCD Data Elements: 1. Header/Document Identifying Information 2. Patient Identifying Information. 3. Patient s Insurance and Financial Information. 4. Health Status of the Patient 5. Care Documentation includes some detail on the patient-clinician encounter history, such as the dates and times of recent and pertinent visits and the purposes of the visits and names of clinicians or providers 6. Care Plan Recommendation includes planned or scheduled tests, procedures or regimens of care.
Health Information Exchange JFCS and MIHS Sharing client data between JFCS and MIHS on two fronts utilizing the current CCD standard: JFCS can pull CCD from MIHS and bring in to EHR JFCS can pull CCD from our EHR and fax over to MIHS for inclusion in their client record
Scope of Integrated Health I feel empowered about my health because of the IHP (Integrated Health Program) - Anonymous satisfaction survey comment I was helped in finding a new and much better P.C.P, Thank you. Groups, workshops, PNP and counseling are all very helpful in dealing with my health. -Anonymous satisfaction survey comment
Health Risk Assessment Demo
Health Promotion Chronic Disease Self Management Healthy Living WHAM Whole Health Action Management Freedom from Smoking American Lung Association N.O.T. Not On Tobacco for youth American Lung Association Know Diabetes Greater Valley Area Health Education Center (GVAHEC) Know Heart Health Greater Valley Area Health Education Center (GVAHEC) Peer to Peer Smoking Cessation - Magellan Plan Well Eat Well Greater Valley Area Health Education Center Basic Tobacco Intervention Skills AZ Department of Health Services Tobacco Treatment Specialist Training AZ Department of Health Services COPD 101 Motivational Interviewing
CDSMP Evidence based best practice Created and tracked by Stanford Less expensive to get staff trained Trainings are easy to get in to Local support and meeting Great tools, exercises Weekly action plan very concrete Very well organized, easy to learn and teach Self management is core Great at fostering social supports within the group Gentle accountability Strong AZ presence Active list serve WHAM Evidence based best practice Specifically created by SAMHSA for behavioral health clients with chronic illnesses Low cost of participant materials Great tools Very well organized Very goal/action oriented Self Management is core Weekly action plan Big social component Relaxed, flexible Can be given to one person or in a group format Relaxation Response Catch it, Check it, Change it
CDSMP Not written for behavioral health population Participant materials higher $16 Not as flexible as WHAM Have to have a class of at least 6-8 to run (Stanford wants min. of 10) WHAM Expensive to train staff Difficult to bring WHAM training locally List serve not active enough Marketing materials not developed yet Little time for clients to expound, get support from the group Very concerned with sticking to the material, may not add anything from outside of CDSMP
Integrated Health Update Form
HRA Report Reporting HRA Comparison Report Integrated Health Update Report Client Caseload Tracker Report Daily staff productivity reports Billed services and unit reports Appointments kept, no billing has occurred
Outcomes PCP Relationship Outcomes and Baseline: We have assisted 66% of clients needing a better relationship with their PCP 75% of surveyed clients reported IH Program helped them develop better PCP relationship 86% of surveyed clients reported better coordination of care amongst health providers Improved Physical Health: We have delivered resources and information regarding health and wellness to 80% of our clients in the IH program 39% of clients needing screening or routine testing received it 55% Of clients walking in with untreated chronic medical disease, received medical appointment within 45 days of beginning the program 33% of clients that reported not managing their diabetes are now successfully managing it and have reduced their A1C levels to below 9% 77% of surveyed clients report they feel an improvement in overall physical health
Outcomes Improved Mental Health: Screen 100% of all IH clients for tobacco use, 112 have been given resources and information on tobacco cessation including formal classes and ASH Line referrals (29) To date, 5 IH clients have stopped the use of tobacco 42% of clients desiring to cut back or stop alcohol use did so 84% of surveyed clients reported be able to manage their symptoms better since joining the program Increased Control over Health: Almost 100 CDSMP participants 78% of surveyed clients reported they were functioning better overall since joining the program Overall Program Satisfaction: 93%
Client Quote on Integrated Care Services CLIENT VIDEO
Mary Jo Whitfield, MSW Vice President of Behavioral Health MaryJo.Whitfield@jfcsaz.org Cheri DeBree, MC Integrated Health Director Cherilyn.DeBree@jfcsaz.org 4747 N. 7 th Street, Suite 100 Phoenix, AZ 85014 Phoenix, Arizona 602-279-7655