Collaborative Care: Case Study of Integrating Primary Care in a Mental Health Setting Beat Steiner MD MPH Professor of Family Medicine UNC School of Medicine & Associate Medical Director Primary Care Services Wakebrook Brian Sheitman MD Professor of Psychiatry UNC School of Medicine & Medical Director Wakebrook
Objectives Examine a reverse co-location model of collaborative care Identify important features of model Present challenges and stimulate discussion on how to overcome challenges Identify others who might be interested in helping us improve this model
The Case for Integrated Care People with severe mental Illness die 25 years earlier than the general population (on average) (60% due to physical health conditions COPD, CAD, Cancer)
Why Reverse Co-Location? Medical home in a community based outpatient practice is right for most patients but not all patients. Patients with severe mental illness:» often need for frequent mental health services» may require specialized care: ability to connect with community mental health resources team based care with focus on behavioral health ability to deal with crisis» may feel more comfortable in behavioral health setting
Inpatient Unit: 16 beds (soon to be expanded to 28)» 500-600 admits per year Residential Facility Based Crisis Unit: 16 beds» 500 admits per year Residential Detox Unit: 16 beds» 900 admits per year; #1 alcohol, #2 opioids Crisis and Assessment Services: 12 chairs» 5000 patients per year Child Psychiatry Clinic Substance abuse treatment program for pregnant and/or parenting women and their children Primary Care Service WakeBrook
WakeBrook Primary Care Service Staffing:» MD Medical Director: 0.4 FTE» MD supervision: 1.0 FTE» FNP/PA: 3.5 FTE Description of Work:» Intake physicals and consultations on units» Full scope outpatient family medicine office for patients with SMI Coordinated and accessible care over time Focus on quality improvement Team based care with behavioral health
Needs Identified on Units 24% 11% 9% 4% HTN COPD/Asthma DM 55% 34% 20% no care X2 years ED visit for dental care current pain CV Dz 77% 74% need CRC 64% 46% 42% use Tobacco need Mammo need Pap need PCP
Early Impact of our Work on Units 40 ED transfers/month from Wakebrook for Medical Reasons 35 30 25 20 15 10 5 0 q1 2013 q2 2013 q3 2013 q4 2013 q1 2014 q2 2014 q3 2014 q4 2014 q1 2015 q2 2015 ED transfers per month
Our Primary Care Practice Team Flex clinicians who work on units Full time RN with care manager role Full time office manager with quality improvement role Pharmacy technician (50%) Dental team (dental students with faculty supervision) Peer support (100%) Note: positions in red being added currently (SAMHSA funded) start up funds provided by UNC HCS and Wake County
Growing the Primary Care Office 120 100 Current Total Panel Size: 238 Goal: 750-1000 100 86 83 94 102 96 80 60 53 61 59 67 53 40 20 28 26 7 7 20 30 27 20 28 35 42 31 31 13 25 0 August 2014 September 2014 October 2014 November 2014 December 2014 January 2015 February 2015 March 2015 April 2015 May 2015 June 2015 July 2015 August 2015 Visits Per Month No Shows Per Month
The Clients in our Primary Care Office Physical Health Diagnoses n % HTN 107 45% DM 43 18% COPD 25 11% CAD 10 4% Psychiatric Diagnoses n % Psychotic Disorder 177 74% Severe Mood Disorder 22 9% Personality Disorder 20 8% Substance Use Disorder 56 24% Insurance Status (%) Medicaid 28% Dual 16% Medicare 26% Other Govt 5% Private 3% Uninsured 22% Behavioral Health Connection UNC ACT team Fellowship ACT team Easter Seals ACT team Carolina Outreach ACT team STEP clinic Naftel WakeMed n % 47 20% 5 2% 2 1% 5 2% 60 25% 15 6% 6 3%
Triple Aim Dashboard for Quality 9/1/2015 Population Health n % Tobacco Use 160 67% BMI >30 133 63% DM with systolic >140 13 30% DM with A1c >9 5 12% HTN with SBP >140 36 34% eligible women with Pap q3 yrs pend pend patients >50 with CRC screen pend pend Cost n % Emergency room visits past 3 mo pend pend Hospitalization past 3 months pend pend Patient Experience n % Time to third available appt pend pend Cycle time pend pend Patient satisfaction pend pend
Challenges Develop long term financial viability» Contracts that pay for value not for volume» Collect data for utilization outside of our office Find most effective and efficient ways to communicate with behavioral health team Measure patient experience