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Managing Care While Staying in the Moment October 8, 2015 Slide 2 Learning Objectives 1.List and describe the core components of the IMPACT/Collaborative Care model of care 2.Identify ways to blend IMPACT and other evidence- based models such as behavioral health consultation 3.Describe the IT and clinical infrastructure needed to provide population-based primary care behavioral health 4.Identify the value of participating in a learning collaborative Slide 3 Definition of Integrated Care The care that results from a practice team of primary care and behavioral health clinicians, working together with patients and families, using a systematic and cost- effective approach to provide patient-centered care for a defined population This care may address mental health, substance abuse conditions, health behaviors, (including their contribution to chronic medical conditions), life stressors and crisis, stress-related physical symptoms, ineffective patterns of health care utilization Peek, C.J. National Integration Academy Council (2013). Lexicon for behavioral Health and Primary Care. Integration: Concepts and Definitions. Developed by Expert Consensus. In Agency for Healthcare Research and Quality Slide 4 The Face of Integrated Care 78 year old male whose family reports depression, agitation, and memory loss. Presents to PCP who orders neurology referral and involves BHC. BHC does phq9 and Montreal cognitive assessment and determines fairly major impairment and depression. SSRI discussed, but patient isn't interested. Never goes to neuro. Later on, he shows up as a transition of care from a psychiatric hospital and is discharged on 2 Alzheimer's meds, Seroquel, and Prozac. Our PCP is very nervous about continuing those meds but consulted with our psychiatrist who educated on the why, advised on what questions to ask the family to determine the root of some of the issues they are seeing, and advised on some possible dosage changes. The PCP was then able to prescribe and the BHCs worked with the family to check in on the depression. The goal for this patient was to keep him out of hospitalization. What the patient really wanted was to go back to Mexico, so the BHC also worked on developing a plan to support this with the patient's daughters who were initially unsupportive. Slide 5 The Face of Integrated Care Patient presents to PCP as depressed with main complaint lack of sleep, no appetite, no interest in doing things, irritability, and recent negative changes at work. He reported insomnia and trouble at home due to the aforementioned reasons. Had failed SSRI trials previously. Got referred to BHC and provider had already started on a tricyclic but he hated it. He had a BHC consult to work on identifying priorities, skill building, general support and a PHQ 9 initial score 15. With psych consult, decided to switch to Remeron. After three weeks he came back and was a changed man. The phq9 went down to 4. He decided to stay on the Remeron for two more months but his depression was so improved and with his new skills he had resolved so many of his source issues that he came off. We still touch base when he comes in to see PCP but the adjustment disorder has completely resolved and he knows we are there when he needs us. Slide 6 Rarely Only Behavioral Disorder Mental Health/ Substance Use Cancer 10-20% Neuro- logic Disorders 10-20% Diabetes 10-30% Heart Disease 10-30% Smoking, Obesity, Physical Inactivity 40- 70% Chronic Physical Pain 25-50% Slide 7 What does work? Core Principles of IMPACT/Collaborative Care Patient-centered team care/Collaborative Care Collaboration not co-location Team members have to learn new skills Population-based care Patients tracked in a registry; no one falls through the cracks Measurement-based treatment to target Treatments are actively changed until the clinical goals are achieved Evidence-based care Treatments used are evidence-based Accountable care Providers are accountable and reimbursed for quality of care and clinical outcomes, not just the volume of care provided Slide 8 Collaborative Care Team Care Model Two processes: 1. Systematic diagnosis and outcomes tracking PHQ-9 to facilitate diagnosis and track depression outcomes 2. Stepped Care Change treatment according to evidence-based algorithm if patient is not improving Relapse prevention once patient is improved Slide 9 Primary Care Provider Role Oversees all aspects of patients care Diagnoses common mental disorders Brief screeners (e.g., PHQ-9, GAD-7) Starts & prescribes pharmacotherapy Introduces collaborative care team and care manager Collaborates with care manager and psychiatric consultant to make treatment adjustments as needed Slide 10 One Treatment Plan Team-based care: patient, PCP, BHC, psychiatrist all involved in developing and carrying out the treatment plan Regular communication through team huddles, shared appointments All members of the team give consistent recommendations Slide 11 Two New Team Members Behavioral Health Clinician (BHC) Patient education/self- management support Close follow-up to make sure pts dont fall through the cracks Support anti-depressant Rx by PCP Brief counseling (behavioral activation, PST-PC, CBT, IPT) Facilitate treatment change/referral to mental health Relapse prevention Consulting Psychiatrist Caseload consultation for care manager and PCP (population- based) Diagnostic consultation on difficult cases Consultation focused on patients not improving as expected Recommend additional treatment/referral according to evidence-based guidelines Slide 12 BHC Role Supports and collaborates closely with PCPs managing patients in primary care Patient education/self- management support Brief counseling (behavioral activation, PST-PC, CBT, IPT) Support anti-depressant Rx by PCP Supports medication management by PCPs Reviews cases with psychiatric consultant weekly Facilitate treatment change/referral to mental health Relapse prevention Slide 13 Psychiatric Consultant Role Caseload-focused consultation supported by BHC Better access: PCPs get input on their patients behavioral health within a day/week vs. months Focuses in-person visits on the most challenging patients Regular communication: Psychiatrist has regular (weekly) meetings with the BHC Reviews all of the patients who are not improving and makes treatment recommendations Slide 14 Measurement-Based Care (PHQ-9) Assists with identification and diagnosis Tracks 9 core symptoms over time Easy to use: can be self-administered and done over the phone A good communication and teaching tool Available in many languages: http://www.phqscreeners.com/ Slide 15 Population/Care Management Use a clinical registry to: Proactively follow up to prevent people from falling through the cracks Systematically track treatment response Facilitate treatment planning and adjustment Combat clinical inertia: patients staying on ineffective treatments for too long Know when it is time to get consultation/get help and when it is time to change treatment Slide 16 Depression Registry Slide 17 i2i Tracks Population Management Software Integrates data from internal and external systems, aggregating data about your entire patient population. Slide 18 i2i Tracks Slide 19 Transforming Practice Through Participation in a Learning Collaborative Slide 20 What is a learning collaborative? Structured approach for change Adopt best practices in multiple settings Uses adult learning principles & techniques Time-limited learning process Shared learning and collaboration Slide 21 Breakthrough LC Model http://www.ihi.org Slide 22 Components of Our LC Learning Sessions Training Manuals Action Periods Apply Skills Test Changes Collaborative Meetings Ongoing TA & Support Measure Outcomes Share Progress Slide 23 Learning Collaborative Process Create Change Package Develop Charter Select Teams Begin Pre- Work Hold Learning Sessions Implement Action Periods Measure Progress Slide 24 The Charter Mission Primary focus of the collaborative Aims Written statements of expected accomplishments Expectations Commitments to meet during LC Community Care Provider agencies Other partners Slide 25 Aims Process Aim 1: By March 31, 2016, 100% of adults, age 18 years and older, are screened for depression using the PHQ-2 within the previous 12 months Process Aim 2: By March 31, 2016, 50% of individuals with a PHQ-9 score >10 are seen by the behavioral health clinician Outcome Aim 1: By March 31, 2016, 50% of individuals with a PHQ-9 score >10 have a 50% improvement in score after 3 months of treatment Slide 26 Select the Teams Quality Improvement Teams (QIT) Executive leadership Clinical/quality improvement Leadership Lead behavioral health provider Health center patient Psychiatrist Intervention faculty Content experts Support and TA teams (Community Care staff) Slide 27 Milestones Slide 28 PDSA Cycles: Plan-Do-Study-Act PDSA cycles are how aims are achieved Small tests of change Conduct one or more each month Measure impact Submit workbook to producer Share progress in monthly collaborative calls Slide 29 Slide 30 Measure Progress on Aims Update monthly Excel workbooks Pre-formatted Automatically graphs progress Submitted monthly to producer Reviewed by facilitator Shared with collaborative Synthesized in quarterly reports Summative final report Slide 31 Process Aim 1 By March 31, 2016, 100% of adults, age 18 years and older, are screened for depression using the PHQ-2 within the previous 12 months Slide 32 Process Aim 2 By March 31, 2016, 100% of patients with a PHQ-9 score >10 are seen by the behavioral health provider Slide 33 Outcome Aim By March 31, 2016, 50% of patients with a PHQ-9 score >10 have a 50% improvement in score within 3 months Slide 34 Monthly Progress Assessment Slide 35 Questions ? Slide 36 Contact Suzanne Daub, LCSW Senior Director, Integrated Care Initiatives, Community Care daubs@ccbh.com Amy Lambert Director, Behavioral Health, La Comunidad Hispana alambert@lchps.org Helen Wooten, LCSW Behavioral Health Consultant, Berks Community Health Center hwooten@berkschc.org