Integration Improves the Odds: Lessons Learned Monday, December 18 th, 2017
Julie Cornell, North America Regional Manager, Global Community Impact
INTEGRATION IMPROVES THE ODDS Lessons Learned Webinar - National Council for Behavioral Health
PRESENTERS Sheila O Neill, LCSW and Kristin Davis, Ph.D.
Thresholds has more than 55 years of experience in evidence-based community mental health services. We improve health outcomes and save money. Thresholds programs are located in the city of Chicago and five surrounding counties in northern IL. Thresholds has challenged and changed psychiatric rehabilitation practices, believing and demonstrating that with the proper supports and treatment, persons with mental illness can begin a recovery that will lead to a more fulfilling life. The agency is an internationally-recognized model of mental health care, and we are expanding our services to include more integrated healthcare.
THRESHOLDS SERVICES Thresholds provides the following behavioral health services: Assertive Community Treatment (ACT) Community Support Housing supports Follow up after Hospitalization (FUH HEDIS quality measure) Supported Education Supported Employment Integrated Healthcare Psychiatric Services Substance Use Treatment In addition, we have tailored programming for specific populations: Veterans Young Mothers Young Adults (16-21) Emerging Adults (18-28) Persons who are Homeless Deaf or Hard of Hearing Commercial Insurance and Private Payers
THRESHOLDS MEMBERS SERVED FY17 TOTAL MEMBERS SERVED: 17,285 100% 50% 11,060 (64%) 6,225 (36%) CONTINUOUS CARE TEAM: 6,225 612 (10%) 2,306 (37%) 3,307 (53%) Touched 73 % CSI CST ACT
THRESHOLDS MEMBERS AT INTAKE: CHARACTERISTICS AXIS 1 DIAGNOSES CO-OCCURRING SUBSTANCE USE 100% 40% Schizoaffective Disorders 50% Bipolar or Major Depression 50% JUSTICE INVOLVED UNEMPLOYED HIGH SCHOOL EDUCATED 49% 90% 73 % *Avg. Income $9,869
Thresholds adds physical health and well-being as a goal area. Family Nurse Practitioners from University of IL College (UIC) of Nursing begin delivering primary care services to members of Thresholds South. Added psychiatry at a later date. 1992 HISTORY OF INTEGRATED CARE AT THRESHOLDS 1998 Second UIC clinic opens at a Thresholds north side location. 2000 Thresholds sought new FQHC partners. 2016 Opened three Integrated Care Centers at Thresholds locations 2017
PATH TO INTEGRATED CARE Coordinated Co-location Integration
INTEGRATED CARE AT THRESHOLDS Delivery System Design ACT and other Thresholds Nursing Substance Use TX Community Support/ACT Team Member Integrated Health Care Pharmacy Physical Space EBPs Social Determinants
INTEGRATION ENGINE*: FACILITATING CARE COORDINATION AND QUALITY CARE *Johnson and Johnson Foundation Funded
Integration Engine A middleware application which transforms, routes, and translates messages Extracts vital data from two health records and allows it to be shared and/or placed in each others EHRs (read-only). Built specifically for health care industry and is used for exchange of health data. Connects legacy systems by using a standard messaging protocol.
INTEGRATION ENGINE All appointment data is shared with Thresholds upcoming appointments, type of appointment, etc. Rates of appointment engagement and follow up (able to break down by Thresholds program, team, type of service, PCP and psychiatry note (from partner to Thresholds EHR) DXs, medications, key health indicators (from partner to Thresholds EHR) Shared Outcomes and focus Blood pressure Diabetes control BMI Smoking
LESSONS LEARNED Compatible partner culture Shared vision and values Commitment of staff time and expertise Commitment to quality and patient outcomes Cross training for staff and co-interviewing new providers Leadership styles and structure Inter-professional communication and collaboration skills
LESSONS LEARNED Complex population and busy staff Staff education, training, comfort with SMI Sharing data/integrated Medical Record Billing/Reimbursement for services longer visits Financial investment and sustainability Overall system is not integrated (hospitals, specialty care)
Primary Care- Behavioral Health Integration Project Rina Ramirez, MD, Chief Medical Officer
Zufall Health Center A Federally Qualified Health Center since 2004 Established as the Dover Free Clinic in 1990 Zufall operates Eight offices in six counties Medical van Dental van Wellness Center NCQA Accredited Patient Centered Medical Home HRSA Designated National Quality Leader CDC Recognized Hypertension Champion Target BP Gold Level 21
Zufall Health 2017 Statistics (Projected) Served 37,000 patients in 125,000 visits 88% at or below 200% of Federal Poverty Level 50% of patients were uninsured 65% of patients were Latino 56% best served in a language other than English
Zufall Health Services Core Services Pediatrics, Adult Medicine, Women s Health, Dental, Behavioral Health, HIV Services, Podiatry, Neurology Supportive Programs 340B Contract Pharmacy, Clinical Pharmacy, Presumptive Eligibility/Enrollment, Case Management & Patient Navigation, Patient Portal Access Community Outreach and Service Programs - Health Education/Screenings, Enrollment Assistance, HIV Testing, Outreach and Programs for Special Populations, School-based dental screening and prophylaxis
Primary Care Integration in the Behavioral Health Setting the Need Enhance access to primary care services for vulnerable, underserved SMI patients by addressing barriers transportation, low income, fear, lack of social support, language barriers Manage chronic medical conditions; Increase needed follow up visits Provide comprehensive services Improve communication and coordinate care Improve clinical outcomes
Our Integration Philosophy Patient-centered, team-based, one-stop shop Trusted clinical staff; Familiar faces, places, processes Patient Navigator as link between primary and BH clinical services Case by case navigation Direct access to PC, multidisciplinary team Expedited access to clinician appointments Sharing of medical and psychiatric information (by informed consent) Communications between the clinical staff at both sites enhanced
First Phase: Collaboration with BH via Patient Navigator, no co-location Partnership with Saint Clare s Medical Center since 2009 the largest provider of BH services in region. Full-time patient navigator (Zufall staff member), located at St. Clare s BH offices Patient Navigator as link/liaison between primary and BH clinical services Patient navigator has access to both BH and medical records PN identifies patients needing services and assesses specific healthcare needs; addresses barriers to access; provide for PC registration and appointment making in the BH setting; assist with follow through, aftercare and linkage to specialty care
Key to Success Patient Navigator Nurture relationship with patient on behalf of the helping system Educate PC practice in the patient s perspective on care and how to address problems; educate patient on health and illness, educate BH staff on Zufall system Teach patients about social articulation how to be a successful patient Foster activation and health behavior change One to one hands-on case navigation
Second Phase: Co-location of services using Mobile Vans* Trial of co-location at separate BH site was unsuccessful Medical van to BH St Clare s outpatient campus Weekly all day sessions, same day of the week Same medical provider sensitive to needs of BH patients Bilingual support staff Physical Exams Acute illness care Continuity of care and follow up visits Preventive screenings Dental screenings/care Women s healthcare Patient Education On-site laboratory and point of care testing
Findings to date Increased access On site, no travel for patients Patient Navigator personal assistance Increase in visits and patients seen Increased demand for appointments Improvement in healthcare outcomes Increased patient and organizational satisfaction Access to multidisciplinary, team-based care Medical Dental Clinical Pharmacy Women s Health
BH Integration Statistics 2017 (Phases 1 and 2) Number of patients 790 Number of visits 3,600 Number of dental visits 1,100 Average number of PC visits/yr 4.5 (3.5 for all Zufall) No show rates 16.6% (17.2% for all Zufall) Percent overweight/obese 74% Percent with hypertension 31% Percent with DM - 17%
Top 5 Diagnoses- BH Integration Psychiatric Schizophrenia Schizoaffective Disorder Affective Disorders PTSD Alcohol/Drug Dependence Medical Overweight/Obese Hypertension Diabetes Tobacco Use Disorder COPD
Clinical Outcomes Tracking from 2013 on Hypertension Diabetes Cervical Cancer Screening Tracking in 2017 Breast Cancer Screening Colorectal Cancer Screening
90% Behavioral Health Integration Program Percent with BP in Control (<140/90) by Year All Zufall 2017 (75%) 80% 80% 70% 69% 67% 60% 61% 50% 48% 40% 30% 20% 10% 0% 2013 2014 2015 2016 2017
90% Zufall Behavioral Health Integration Program Diabetes in Control/Uncontrolled by Year All Zufall Controlled 73% 80% 78% 74% 73% 77% 70% 66% 60% 50% 40% 34% Under 9 Over 9 30% 22% 26% 27% 23% 20% 10% 0% 2013 2014 2015 2016 2017
100% Zufall Behavioral Health Integration Program Cervical Cancer Screening Rates by Year All Zufall Rates 83% 90% 80% 70% 70% 60% 50% 52% 60% 61% 61% 40% 30% 20% 10% 0% 2013 2014 2015 2016 2017
New Clinical Measures Breast Cancer Screening BH Patients 51% Colon Cancer Screening BH Patients 59% All Zufall 55% All Zufall 62%
Lesson Learned - Financial Impact Improvement in clinical measures = potential performance bonuses Increase in visits = increase in fee for service revenue High risk pool = enhanced risk scoring with favorable revenue from ACO Access to Primary Care and Medications = reduced ED costs 340B Savings = increased revenue from insurances Inefficiencies in scheduling in mobile services = decreased productivity PN Services sustained by grant funding Management and oversight of program, QA processes not funded
Lessons Learned - Challenges PCP knowledge psychiatric conditions and medications Sharing of records, data and outcomes Adapting to different practice models Managing two different payment systems State regulations matter Size of partner organizations matter
Lessons Learned Personal attributes as important as processes Leadership support with devoted resources Time for trainings and meetings Infrastructure Performance Improvement team/processes
What s Next Use data to improve care, offer additional needed services, focus on areas that need attention Increase team interactions with scheduled meetings, updated procedures and protocols, case reviews Improve care coordination through HIE Celebrate success in clinical achievements Continue to explore integration models
Thank you! Rina Ramirez, MD rramirez@zufallhealth.org
Integrated Care for People with SMI
CHCS Mission Improving the lives of people with mental health disorders, substance use challenges and intellectual and developmental disabilities
Trauma Informed Care
Client Population Insured Integrated Clinic CHCS ALL MEDICAID 63.3% 49.5% UNFUNDED 24.3% 44.4%
Client Population Integrated Clinic CHCS ALL Above Poverty 45% 64% Below Poverty 55% 36%
Integration Model The Need Technical Clinical Financial Operational
Outcomes Capacity To Serve Patients Improved Clinical Patient Outcomes Patient Experience Improvement
Clinical Financial Lessons Learned Structural Policy
Integrated Care: Zara Suicidal Behaviors Aggressive Outbursts Somatic Complaints Culture & Language Barriers
Questions?