Community Counseling Centers, Inc. & North Country Health Care Holbrook & Show Low Navajo County Communities 9/28/11
The CCC multi-faceted approach to an integrated health program with North Country Health Care is proposed to include: North Country primary care services will be located in our extended outpatient site in Show Low beginning with four hours per week and ultimately leading to one full day per week. CCC will locate a Behavioral Health Professional in the North Country Health Care clinic in Holbrook beginning with four hours per week and ultimately leading to one full day per week.
Integrated Health Care BHP 5 A s = Assess, Advise, Agree, Assist, Arrange Dr Christopher Hunter Assess Risk Factors, Symptoms, Attitudes, Preferences Arrange Specify plan for follow up, (visits, phone calls, mail reminders) Personal Action Plan 1. List goals in behavioral terms 2. List strategies to change health behaviors 3. Specify follow up plan 4. Share plan with clinical team Assist Provide information, teach skills, problem solve barriers to reach goals Advise Specific, personalized options for treatment, how symptoms can be decreased, functioning of life health improved Agree Collaboratively select goals based on patients interests and motivation to change
CCC receives NARBHA identified high risk patient data from Johns Hopkins University ACG predictive modeling software, identifying mutual medical/mental health patients. CCC will utilize a Health Coach to oversee and provide specialized services to dually enrolled identified patients noted to be at risk patients. Our Health Coach will assist coordinating care between primary health care providers and behavioral health care providers. The Health Coach will oversee and provide referrals to our Healthy Living Workgroups.
John Hopkins NARBHA Registry Identified High Service Needs CCC Patients CCC Health Coach Outreach & Engagement * Letter or call to invite to program * Engage and/or enroll in program * Administer the SF 12 Patient Questionnaire * Assist/Develop Treatment Plan * Short Long term goals identified * Identify frequency of services Integrated Physical BH Treatment * Regular PCP appointments * Regular mental health appointments * Health prevention screening * Wellness programs * Smoking cessation * Exercise & stress management * Weight reduction *Disease/physical condition management * Collaboration with PCP & CCC Care Team Reevaluate Treatment Response Insufficient Response/Relapse Consult with Care Team: PCP, Psychiatrist, & Clinician Adjust Treatment Complete Response Maintenance Relapse Prevention Plan Monthly telephone follow up
Essential elements: Improve medical and behavioral health care with Health Coach availability on site or in OP clinic. Improve patient communication with primary care provider and psychiatrist to improve treatment guidelines and/or change treatment plans. Motivate patients to engage in self care, strengthen self management skills, build patient confidence. Reduce inappropriate health care costs and inpatient hospitalization. Educate patients about medical/mental health issues.
Use of stepped care adjusting treatment based on clinical health outcomes Target improvement of 40% percent reduction in symptoms within 6 months If patient is not significantly improved during the administration of the SF-12 tool, a change in their health care plan will be recommended. The recommendation can include a increase, or decrease in their wellness plan activities, utilization of PCP or mental health visits, blood pressure level, cholesterol values, body mass index, medication dosage, a change to a different medication, addition of psychotherapy, a combination of medication and psychotherapy, or other treatments suggested by the team.
Goals: Greater self-efficacy Completion of six sessions of Healthy Living Workshops Greater energy Considerably greater quality of life Fewer social role limitations Better psychological well-being Lower health distress More exercise and relaxation Greater partnerships with clinicians
Improvements in: Exercise Cognitive symptoms Communication with physician Self-reported health Health distress Fatigue Disability Social/role activity limitations Pain management, shortness of breath, or psychological well being
Monitoring and tracking for outcome results of effectiveness to measure: Percentage of Registry patients, Hospitalizations and ER visits, Medication appropriateness and adherence, Follow up after hospital discharge, Coordination of care, Patient and staff satisfaction, Service utilization, Patient goal attainment, Quality of life, Self-perceived health status with SF-12 tracking results.
John Hopkins Registry Report: 305 total CCC patients CAR11 Lipoid metabolism, 137 participants ENDO6 type 2 diabetes w/o complications, 109 participants total ENDO7 - type 2 diabetes with complications ENDO8 - type 1 diabetes w/o complications END09 - type 1 diabetes with complications MUS01 Musculoskeletal, 255 participants total MUS03 Degenerative joint disease MUS013 Cervical pain syndrome MUS14Low back pain PSY103Tobacco Use, 60 participants NI03 Obesity, 82 participants