Lessons Learned: Using a reverse co-location strategy to provide quality,

integrated health care to people with serious mental illnessFairmont Primary Care Center at Horizon House

Ryan Clancy, PA-C,MSHS, MA, Physician Assistant, Delaware Valley Community Health (DVCH)Barbara Cohen, MSW, LSW, Director of Special Projects in Behavioral Health, Horizon House (HH)David Dunbeck, MSW, LSW, Vice-President, Homeless Services, HHKyle McKinley, BSN, RN, Nurse Care Manager, HHBrenda Robles-Cooke, MBA, Vice-President and Chief Operating Officer, DVCH

Collaborative Family Healthcare Association 13th Annual ConferenceOctober 27-29, 2011 Philadelphia, Pennsylvania U.S.A.

Session # G2aOctober 28, 20111:30 PM

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Faculty Disclosure

We have not had any relevant financial relationships

during the past 12 months.

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Morbidity and Mortality in People with Serious Mental Illness*

People with serious mental illness (SMI) die on average 25 years earlier than the general population

While suicide and injury account for about 30-40% of excess mortality, 60% of premature deaths are due to preventable medical conditions such as cardiovascular, pulmonary and infectious diseases

These preventable medical conditions are linked to high rates of modifiable risk factors e.g., smoking, drug/alcohol use, reduced access to quality primary/specialty health care.

*Parks, J., Svendsen, D., Singer, P., Foti, M.E., Morbidity and Mortality in People with Serious Mental Illness, National Association of State Mental Health Program Directors, October 2006

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Objectives

• Specify rationale for creating integrated “health homes” for people with serious mental illnesses

• Describe pros and cons of using a reverse co-location strategy to meet the health care needs of people with serious mental illnesses

• Identify steps involved in successfully co-locating primary care in a Community Behavioral Health Organization

• Identify core components of a successful partnership to deliver quality, integrated health care to people with serious mental illnesses using a reverse co-location strategy

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Expected Outcome

Attendees will be better able to evaluate, and, if appropriate, implement a reverse

co-location strategy as a way of improving the quality of health care for people with

serious mental illness.

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Who We Are

Horizon House: a cornerstone provider of community-based recovery-oriented services to 4,500+ people impacted by psychiatric and developmental disabilities and homelessness throughout Southeastern PA and DE.

Delaware Valley Community Health (DVCH): a community-focused healthcare organization that operates 6 Federally Qualified Health Centers in Southeastern PA. DVCH provides comprehensive healthcare to 42,556 people annually.

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Specialty behavioral health care providers act as “de facto health homes” for people with serious mental illness who experience:

Barriers to healthcare access Stigma, Transportation, Reluctance to serve Medicaid patients

Difficulties building trust, navigating complex healthcare system

Fear Fragmentation of care

Why co-locate primary care in a specialty behavioral health org.?

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How integrated is a reverse co-location model?

Minimal Basic:

At a distance

Basic:On-site

ClosePartly Integrated

CloseFully Integrated

Collaboration Continuum*

*Collins, C., Hewson, D.L., Munger, R., Wade, T., Evolving Models of Behavioral Health Integration in Primary Care, Milbank Memorial Fund, 2010

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Using a reverse co-located strategy for people with serious mental illness

o Pros• Improved access to/use of physical healthcare care

for preventive, acute and chronic care• Reduction of barriers:

• transportation • stigma • system navigation challenges• bias against Medicaid patients• trust issues• Lack of provider continuity

• Reduction of ER visits

• Provider proximity• increased potential for better:

• communication• collaboration

• coordination 9

Using a reverse co-located strategy for people with serious mental illness

Cons Delivery of care through 2 separate

organizations with different Cultures Treatment philosophies Technologies Recordkeeping/documentation Billing systems• Requires lots of creativity/problem-

solving

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Steps involved in co-locating primary care: Finding the right partner

o The right partner Commitment to primary care Experience with/commitment to safety net

population Similar mission Creative problem solver

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Steps involved in co-locating primary care: Finding the right partner

Execute a Memorandum of Understanding(toolkit)

Develop concept jointly

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Steps involved in co-locating primary care: analyze feasibility

Sufficient traffic at site? Existence and nature of participant

insurance coverage? Currently receiving healthcare? Level of satisfaction with current PCP? Willingness to change PCPs? Appropriate space available for health

center?

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Steps Involved in co-locating primary care: Financial Projections

• Start-up ($40-50K) Renovations Fit out costs Electronic health record Volume buildo Projected Visits: Year 1: 3,250

Annualized cost base Breakeven analysis

16 visits/day after 6 months

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Steps Involved in Co-locating Primary Care: Decision to proceed

o Board Approvals Legal Agreement (toolkit) HRSA Change in Project Scope request

(toolkit) Space renovations plan (toolkit)

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Steps Involved in Co-locating Primary Care: The Initial Bare Bones Model

Staffing (DVCH): 3.1FTE Physician assistant (1FTE) Team leader medical assistant (1 FTE) Medical assistant /front desk clerk (1 FTE) Physician (.10FTE)

Space Plan*(HH) 2 exam rooms, 1 multipurpose room/lab Staff room waiting room reception area

*Toolkit 16

Steps involved in co-locating primary care: getting site approvals

HRSA Medicaid Managed Care Organizations

Identify key players as early as possible Notify re space planning Schedule site visits Time frame for addition to insurance panel Offer courtesy visits until health center added

to panel

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The Health Center on Opening Day 9/7/10•Insurance eligibility assistance•Adult primary and preventive care and health education*•TB Testing •Lung function testing (Spirometry)•EKGs•Immunizations•Onsite lab services•Referrals to specialists/help in making appointments •Physician available by phone after hours•Appointment Reminders

•OB/GYN Dental, Podiatry and Health Education Group Services (at DVCH’s Health Center at 1412 Fairmount Avenue) • Prescriptions: filled through patients’ current pharmacy.• Psychotropic medications: prescribed by behavioral health providers.Ophthalmology and/or optometry services: Referrals to Wills Eye Hospital.

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SAMHSA awards Horizon House funding on 9/30/10

• Supercharged projecto Nurse Care Manager (1FTE)o 2 Peer Specialists (1 FTE, 1 PTE)o Health Educator (1FTE)o Health Integration Specialist (1FTE)o Data Coordinator (1FTE)

• Start-up support

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The Health Center: 12 months after opening

Unduplicated number of patients:

385 NA

Total Visits: 1,884 3,250

Average visits per day 8.9 16

Average number of visits per person

4.9 2.9

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Actual Budget

Core Components of Successful Partnership: The Right Staff /Staffing Pattern

Characteristics Diverse Belief in holistic, client-centered services Experience serving safety net population Willing to give up preconceived notions Creative – willing to try new things Team players

Move beyond traditional health center staffing model – roles of staffo Phase-in staff/schedule

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The Core Components of a Successful Partnership: Marketing

• Pre-health center opening marketing activities generated daily average of 7.6 visits in first full month

• Participants needed support to change PCPs were sometimes happy with the healthcare

they weren’t receiving Often looked to others in making decision to

change PCPs • Had initial concerns about

confidentiality/sharing of information

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The Core Components of a Successful Partnership: Marketing

What worked Easy access, warm, professional

environment Personalized, face-to-face

outreach/education Health and wellness activities Variety and persistence Engagement by peer specialists

What didn’t work? Educational materials/flyers/brochures

without the personal touch

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Core Components of Successful Partnership: Anticipate /address cultural differenceso Cultural differences between the two

organizations emerged quickly Pace/Volume/process Belief in individuals’ capacities Language Wellness/recovery focus

o Documentation/paperwork o Plan time for cross-agency/-cultural trainingo SAMHSA/UMass-sponsored trainings for BH staffoBH trainings for DVCH staff

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Core Components of a Successful Partnership: Information Sharing

o Information sharing at individual and organizational levels is a challenge • 2 different, independent charting/record-

keeping systems

• Different technology More stringent state regulations re sharing of

behavioral health information Participant concerns re sharing behavioral

health information with physical healthcare providers and vice versa

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Core Components of a Successful Partnership: Information Sharing

o Get the right information to the right person/place at the right time

• Educate participants about benefits of health information sharing

• Releases (toolkit) Timely updates to both organizations’ charts

• Program liaisons• Scan information in• Provider exam form (toolkit)

Create forums for communication• Daily interface/feedback• Weekly clinical meetings• Monthly steering committee meetings

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Core Components of Successful Partnership: Specialty Care Referrals and Follow-up

• Significant need for specialty care o Preventive screenings

o mammography o colonoscopy

o Diabetic careo ophthalmologyo podiatry

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Questions???

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Contact Information

Ryan Clancy, PA-C,MSHS, MA Physician Assistant, Delaware Valley Community Health (DVCH) @dvch.org

Barbara Cohen, MSW, LSW Director of Special Projects in Behavioral Health, Horizon House (HH): barbara.cohen@hhinc.org

Brenda Robles-Cooke, MBA, Vice-President and Chief Operating Officer, DVCH @dvch.org

David Dunbeck, MSW LSW Vice-President, Homeless Services, HH: david dunbeck@hhinc.org

Kyle McKinley, BSN, RN Nurse Care Manager, HH: kyle.mckinley@hhinc.org

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Session Evaluation

Please complete and return theevaluation form to the classroom

monitor before leaving this session.

Thank you!

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