© 2015 cherokee health systems all rights reserved a roadmap to integrated care: triumphs and...

© 2015 Cherokee Health SystemsAll Rights Reserved

A Roadmap to Integrated Care:Triumphs and Trials of a Long-Tenured

Integrated Delivery System

Branson, MissouriJune 3, 2015


Our Mission… To improve the quality of life

for our patients through the blending of primary care and behavioral health.

Together…Enhancing Life


Overview of Cherokee Health Systems

Blending Behavioral Health into the Patient-Centered Medical Home

Transforming the Delivery of Behavioral Healthcare

Enhancing the Patient Centered Medical Home


Cherokee Health Systems

Last year: 64,300 patients 488,209 Services

New Patients: 16, 672 Number of Employees: 620

Provider Staff: Psychologists - 51 Cardiologist - 1 Psychiatrists - 10 Primary Care Physicians - 24 Nephrologist - 1 NP (Psych) - 10 NP/PA (Primary Care) - 39 Pharmacists - 11 LCSWs - 69

Comm. Health Coord. - 37 Dentists - 2


HAMBLEN

GRAINGER

CLAIBORNE

HAMILTON

MCMINNMONROE

LOUDON BLOUNT

SEVIER

KNOX

COCKE

JEFFERSON

UNION

CAMPBELL

ANDERSON

Tennessee

Kentucky

NorthCaro l ina

Virg in ia

Georg ia

Smoky Mountain National Park

Cumberland Gap

National Park

Cherokee Health Systems Together…

Enhancing Life

Primary Service Area


Knoxville/Knox County, TN

Population: 655,400


Cherokee Health SystemsWashburn, TN 37888

Population – 645


Cherokee Health SystemsPenetration into the General and Medicaid Populations

• 3 year (FY2012-2014) penetration into the general populationUnduplicated patients

96,964Total area population

1,019,386Penetration

9.5%

• 3 year (FY2012-2014) TennCare (Medicaid) penetrationUnduplicated Medicaid patients 41,027Total Medicaid enrollment 178,212

Penetration 23.0%


Strategic Emphases

Blending Behavioral Health and Primary Care

Outreach to Underserved Populations

Training of Health Care Professionals

Population-Based Care


Strategic Emphases

Telehealth Applications

School-Based Health Services

Safety Net Preservation

Value-Based Contracting


BAN

K O

F CO

MM

ERCE

– M

ORR

ISTO

WN

, TE

NN

ESSE

E

MEN

TAL

HEA

LTH

CEN

TER

OF

MO

RRIS

TOW

N1960

Original CHS Office


Cherokee Health SystemsForks in the Road/Epochs of Development

• Rooted in the mission of community mental health

• Circuit riding outreach into primary care

• Primary care operations

• Embedded Behavioral Health Consultant role

• Blending the cultures, becoming an FQHC

• Behaviorally enhanced Healthcare Home


Cherokee Health Systems:Merging the Missions of

CMHCs and FQHCs


Community Mental Health Centers: What were they?What are they? What happened?

• Historical roots – Action for Mental Health (1961), Community Mental Health Center Act (1963), 1960’s social activism

• Community Mental Health Centers -- the initial model

• Federal block grants gave the States authority over the program

• Psychosocial rehabilitation and “priority populations”

• Managed care and behavioral health carve-outs

• Advocacy/consumer groups, peer support and recovery models

• Federal, State and Medicaid cutbacks


Community Health Centers: What were they?What are they? What happened?

• Historical roots – “War on Poverty”, Economic Opportunity Act

(1964), 1960’s social activism

• Neighborhood Health Centers -- the initial model

• Avoided Federal block granting, Federal authority maintained

• Stability of mission throughout history

• Service expansion grants for mental health services

• Central to Federal health policy


Blending Behavioral Health intothe Patient Centered Medical Home

Cherokee Health Systems’ Clinical Model


Blending Behavioral Health into Primary CareCherokee Health Systems’ Clinical Model

Behaviorists on the Primary TeamThe Behavioral Health Consultant (BHC) is an embedded, full-time member of the primary care team. Psychiatric consultation at the point of care.

Service DescriptionThe BHC provides brief, targeted, real-time assessments/interventions.

Typical Service ScenarioWhen clinically indicated, PCP “hands off” patient to BHC.Collaboration on a plan of care follows.


Role of Behavioral Health Consultant (BHC)Scope of Practice

• Available “on-demand”

• Management of psychosocial aspects of chronic and acute diseases

• Application of behavior change to address lifestyle and health risk issues

• Consultation and co-management of mental health and psychosocial issues


Considerations for PCP Referral forBehavioral Health Concerns

• Diagnostic clarification and intervention planning• Facilitate consultation with psychiatry regarding psychotropic

medications• Behavior and mood management• Suicidal/homicidal risk assessment

• Substance abuse assessment and intervention• Panic/Anxiety management

• Interim check of psychotropic medication response• Co-management of somaticizing patients

• Parenting skills• Stress and anger management


HEALTH BEHAVIOR/DISEASE MANAGEMENT• Medication Adherence• Weight Management

• Chronic Pain Management• Smoking Cessation

• Insomnia/Sleep Hygiene• Psychosocial & Behavioral Aspects of Chronic Disease

• Any Health Behavior Change• Management of High Primary Care Utilization

Considerations for PCP Referral forBehavioral Medicine Concerns


• 12 yo male with abdominal pain (new) 96150• 40 yo male with chronic depression, DM, HTN (f/u) 90832• 58 yo female with fibromyalgia, insomnia (new) 96150• 44 yo female with chronic pain, suicide attempt (f/u) 90832• 58 yo male with post-MI, hx SA and meth lab (f/u) 90832• 59 yo female with HTN, DM, CAD, Depression (new) 90791• 56 yo male with Panic, Obesity (f/u) 90832• 52 yo female with grief (new) 90791• 13 yo male with obesity, weight management (f/u) 96152

9 PATIENTS IN 4 HOURS

An Afternoon in the Life of a BHC


The Behavioral Health Consultant in Primary Care Characteristics, Skills and Orientation to Practice

Characteristics• Flexible, high energy level• Team Player• Interest in health and fitness

Skills• Finely honed clinical assessment skills• Behavioral medicine knowledge base• Cognitive behavioral intervention skills


The Behavioral Health Consultant in Primary Care Characteristics, Skills and Orientation to Practice

Orientation to Practice• Action-oriented, directive, focus on patient

functioning• Emphasis on prevention and building resiliency• Utilizes clinical protocols and pathways• Invested in educating patients, health literacy


The Integrated Care Psychiatrist

• Access and Population-Based Care• Enhance the Skills of Primary Care Colleagues

• Treatment Team Meetings• Telepsychiatry

• Stabilize Patients and Return to Primary Care• Co-Management of Care


Medical Appointment with PCP PCP & BHC Discussion BH Consultation PCP & BHC Discussion BHC and/or PCP

Consults Psychiatry

The 5 Core Components


The Patient Centered Medical Home

A PCMH puts patients at the center of the health care system, and provides

primary care that is “accessible, continuous, comprehensive, family-centered, coordinated,

compassionate, and culturally effective.” (American Academy of Pediatrics)


PCMH “Joint Principles”• Personal physician• Physician led practice team• Whole person orientation• Care is coordinated and integrated• Quality and safety are hallmarks• Enhanced access to care• Payment reform

Adopted by AAFP, AAP, ACP, AOA Feb., 2007


NCQA

• National Committee on Quality Assurance (NCQA)

– 501(c)(3) dedicated to improving health care quality

– NCQA offers “recognition” programs for various aspects of clinical care: diabetes, cardiovascular disease, back pain

– One of the recognition programs is for PCMH

– 3 levels of accreditation: Level 1 (lowest), Level 2, and Level 3 (highest)


PCMH 2014


Re-engineering Primary Care: An Integrated Team Based Model

• Functions of care delivery shared across team • Access to BH expertise “where behavioral

problems shows up” • Improved communication • Improved care coordination• Expanded health management support• Supported patient engagement


Fostering the Informed and Activated Patient

• Assess readiness to change.• Mutually establish behavioral goals and behavior change

strategies.• Employ motivational interviewing and problem focused

interventions.• Support patient self-management and self-regulation skills.• Foster resiliency and personal responsibility for health.


Cherokee’s Patient-Centered Medical Home Model

• Embedded Behavioral Health Consultant on the PC Team

• Real time behavioral and psychiatric consultation available to PCP

• Focused behavioral intervention in primary care

• Behavioral medicine scope of practice

• Encourage patient responsibility for healthful living

• A behaviorally enhanced Healthcare Home


A Roadmap to Integrated Care:Triumphs and Trials of a Long-Tenured

Integrated Delivery System

Branson, MissouriJune 3, 2015

CFO’s Perspective


CFO Job Qualifications• Healthcare Experience: none• Insurance Experience: none• Management Experience: none• Age: Mid-20’s• Eager to Learn• Willing to Work Hard• Desire to Succeed


Firstly, I’d like you to put aside your preconceived notions of what constitutes “funny”…


Growing Up at Cherokee…• 1960 – Incorporated• 1978 – Dennis Freeman Hired as CEO• 1984 – Blaine Health Center• 1987 – Union-Grainger Primary Care• 1992 – Managed Care Growth• 1994 – TennCare Began• 1995 – CHS vs. Magellan• 2006 – Relocation & Growth


19791981

19831985

19871989

19911993

19951997

19992001

20032005

20072009

20112013

2015 $-

$10,000,000

$20,000,000

$30,000,000

$40,000,000

$50,000,000

$60,000,000

Cherokee Health Systems Revenue History

FQHCManagement

1st Primary Care

TennCareBegins

CHS vs.Magellan

EconomyDown

P4P


Everything you ever wanted to know about

behavioral health integration but were

afraid to ask!The Groundbreaking Guide for the Rest of Us!Mission, Model, Manpower, Money

Investing in Technology

Financing the Model for Sustainability

Dennis S. Freeman, PhDParinda Khatri, PhD

Foreword by Bob Franko, world-renowned IC Blogger

Who says behavioral health doesn’t fit in Primary Care!?

Integrated Care

Find the REAL WORLD

answers you’ve been looking for!


Where does the CFO Fit?


Management Structure


Infrastructure• Financial Systems• Technology• Facilities•Revenue Cycle


Financial Systems• General Ledger / Accounting Structure• Payroll / Personnel • Purchasing & Logistics• Banking• Debt• Investments


Behavioral

Dental

Laboratory

Medical

Developmental Pharmacy

Radiology

Reporting Challenges of Integration


Behavioral

Dental

Laboratory

Medical

Developmental

Pharmacy

Radiology

Integration?


Integration!

Behavioral

Dental

Laboratory

Medical

Developmental

Pharmacy

Radiology


• Integrated Organization

• Segregated Business Units

Reporting Challenges


Technology Systems• Records Management & Documentation (not IT)

– Paper– Electronic

• Communications– Phones, Faxing & Communications– WAN, Internet, Video

• Maintenance & Support– Hardware & Software

• Reporting Capabilities


(16)


Facilities• Construction & Renovation• Maintenance• Cleaning • Security & Safety

– Video– Access Control– Alarms

• Parking


GroupRoom

Office OfficeOffice Office Office Office

5th Street – 6 Weeks Before Integration


Integration (Phase 1)

Office OfficeOffice Office Office


Office Office Office Office Office




Office


Phase 4


Phase 5


Walter P. Taylor Homes Aerial View – 2015

Proposed Project Site


Revenue Cycle• Contracting• Credentialing• Practice Management System• Registration & Verification• Coding & Charge Entry• Billing & Follow-Up• Collections• Chart Audits• Feedback & Training


4 Disciplines of Execution

• Focus on the Wildly Important

• Act on Lead Measures

• Keep a Compelling Scoreboard

• Create a Cadence of Accountability


Cherokee’s WIGs

Improving Access

Enhancing the Clinical Model


How will WE help Cherokee accomplish the Wildly Important

?


Accounting

Purchasing

Facilities

Credentialing

Revenue Cycle

To support the organization with effective performance of financial

services and communication of financial information

To maximize revenue on our services in an ethical, and caring manner

To arrange for our staff to have the resources they need in the most cost-

effective and timely manner

To ensure that corporate properties strengthen our work and enhance the

patient experience

To verify that our providers are qualified and privileged to serve our patients and

generate revenue


What do I want to accomplish this year?

• Grow a Culture of Excellence– Set the standard– Adequate is not adequate– Errors are not acceptable

• Empower Positive Leaders– Trust/Integrity– Listening– Ownership

• Enhance Corporate Performance


A CFO’s Guide to Survival (and Success) in Integrated Care

• Service Mentality– Money is a TOOL, not the MISSION

• Strive for Improvement in Everything– If it ain’t broke, BREAK IT.

• Listen and Observe– Proximity to patients trumps back-office mandates

• Follow the Golden Rule– Matthew 7:12


Questions

?

© 2015 cherokee health systems all rights reserved a roadmap to integrated care: triumphs and...

Documents