Download 2016.11.15 BHI Care Processes and Connections (Block)

HealthVisions
Delmarva
improved health, healthcare quality and experience, lower healthcare costs and
improved provider experience
Bruce Block, MD
As Chief Learning and Medical Informatics Officer for the
Pittsburgh Regional Health Initiative (PRHI), Dr. Block provides
technical assistance, training and coaching to clinical practices.
He is the regional physician lead for PCMH, Meaningful Use,
Behavioral Health Integration, Community Health Workers and
Quality Improvement Training projects.
He has 40 years of practice experience in rural and urban underserved settings. He
joined PRHI after 30 years on the faculty of the Shadyside Hospital Family Medicine
Residency Program in Pittsburgh.
Bruce Block, MD has indicated that he has no financial conflicts of interest relevant to this
presentation.
 Identify the workflows required to respond to the needs of patients who have
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been identified with behavioral health problems
Describe the staff skills and relationships needed to provide case
management and care coordination
Explain the methods for building patient self-management and shared
decision-making into clinical care
Indicate the care linkages needed to extend care beyond the exam room
Recognize the opportunities to sustain behavioral health integration
innovations
Care Processes and Connections
CARE PLANNING
SYSTEMATIC CASE REVIEW
CARE LINKAGES
AND OUTREACH
SUSTAINABILITY
CONTINUING ASSISTANCE
Adapted from AIMS Center
Copyright 2016 JHF/PRHI
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Integrated Care Workflow
Screening, Diagnosis, Engagement
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Primary Care Workflow
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Primary Care Team Proactively Screens for
Depression as Part of the Routine Check-in and
Rooming Process
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Primary Care clinician Assesses Patient in Light of
PHQ-9 Results
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PCP and Patient Create Treatment Plan and
Goals for Both Behavioral and Physical Health
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PCP Connects Patients to a Trained Care
Coordinator after a “Warm Handoff”
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Care Coordinator Connects the Patient to the
Care Team, Skills and Resources
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Communicates and coordinates with PCP
Develops rapport with patient
Provides frequent contact between PCP visits
Provides education and self-management support to help patients reach goals and treatment
adherence
Tracks patient progress with a care management tracking system
Reviews problem cases with consulting psychiatrist and medical consultant each week
With PCP approval, implements care plan modifications
Connects patient to community resources
Completes a maintenance plan once goals are sustained
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Integrated Care Workflow
Care Coordinator Intake & Review
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Primary Care
Workflow
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Care Planning
Begins with Patients’ Goals
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Why are Patient Goals Important?
People are more likely to make the most progress
improving their health when they are focused on
activities that are meaningful to them.
Patient goals describe activities that will make a
difference in the quality of their lives.
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What are Patient Goals?
Patient goals provide a tool for promoting a patient-centered approach to
care. They should include:
• Meaningful activities (e.g. walking)
• Feelings (joy), or
• Capabilities (energy)
that the patient desires, but cannot achieve as a result of their social status,
environmental setting, illness or injury.
I want to be walking in the
park with my granddaughter…
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I want to enjoy visiting with
my family…
I want to have the energy to
attend my niece’s
graduation…
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How Do We Help Patients Achieve Their Goals?
Action steps are the self-care activities
that patients use to reach their
personal goals.
For example, if the patient’s goal is
“being able to walk with my grandchild
in the park,” the action step should
describe what the patient wants to
start with to gradually improve her
walking ability
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“I plan to walk in the park with my
granddaughter twice weekly for at
least 30 minutes by October 1st.”
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Patient-Centered Care
Person-Directed Care
Motivational Interviewing
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Engaging
to involve the client in talking about issues, concerns and
hopes, and to establish a trusting relationship.
Focusing
to narrow the conversation to habits or patterns that the
client wants to change.
Evoking
to increase the client’s sense of the importance of change,
their confidence about change, and their readiness to change.
Planning
to develop the practical steps clients want to use to
implement the changes they desire.
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Prepare patients
for self-care
before they leave
the office
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Help patients
pursue their
goals with
practical
action steps
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Document the
care plan in the
EHR to engage
other team
members in
supporting the
patient’s
efforts
Mauksch and Safford.
“Engaging Patients in Collaborative Care Plans”.
FAMILY PRACTICE MANAGEMENT
2013. p.35-39.
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Structured
Documentation
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Integrated Care Workflow
Systematic Case Review and Tracking
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Primary Care
Workflow
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New Patients and Sub-Optimal Progress
Screenshots from UW AIMS Center’s CMTS
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Systematic Case Review
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Access to:
• EHR and Internet Resources
• Remote Communications
• Meeting Space
• Computer Projector
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Consultants:
• Primary Care
• Psychiatrist
• Pharmacist
• Social Worker
• Psychologist
Care Coordinators and Behavioral
Health Consultants
Adapted from AIMS Center
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Case Review Presentations
Initial (7-10 minutes)
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Brief ID and Profile
Current behavioral health issues
Prior history
Social and environmental factors
Other medical problems
Current treatment
Patient goals and concerns
PCP assessment and plan
Recommendations
Subsequent (3-5 minutes)
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Brief ID
Progress toward patient goals
Progress toward team goals
Current treatment
PCP assessment and plan
Patient concerns
Care team concerns
Recommendations
Up to 20 cases reviewed in a two hour session
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Care is Supported by a Tracking System
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Care coordinators can use data from the EHR or Registry to
follow the progress of individual patients
…or to view the entire caseload to focus priorities:
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Lapsed or overlooked care
Missing data
Worrisome test results
Hospital and ED use
Screenshots from UW AIMS Center’s CMTS
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The Tracking System Also Supports Protocol-Based Case
Management
Follow-up with Patients is Prompted Automatically…
…based upon the Care Management Protocol
Severity
Overdue reminder IF…
most recent PHQ-9 was 10 to 19
not seen in last 28 days
most recent PHQ-9 was 20 or more
not seen in last 14 days
The prompt is displayed in red if the patient is more than 14 days overdue
Screenshots from UW AIMS Center’s CMTS
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Every Certified EHR has Report Writing Features to
Support Care Management
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Common Metrics Allow Comparison of Results Across
Clinicians, Modalities & Sites to Identify Best Practices
The PQRS reporting capability of the EHR can also be used to visualize
participation in behavioral health integration initiatives.
NQF code
0004
0028
0104
0105
0108
0418
0710
0712
1365
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Measure
Initiation and Engagement of Alcohol and Other Drug Dependence Treatment
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Adult Major Depressive Disorder (MDD): Suicide Risk Assessment
Anti-depressant Medication Management
ADHD: Follow-Up Care for Children Prescribed ADHD Medication
Preventive Care and Screening: Screening for Depression and Follow-Up Plan
Depression Remission at Twelve Months
Depression Utilization of the PHQ-9 Tool
Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment
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Integrated Care Workflow
Behavioral Health Consultation and Consulting Psychiatry
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Primary Care Workflow
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Behavioral Health Consultant (BHC)
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Receives direction from
the primary care team
Manages the treatment
plan with the patient
Provides SBIRT, health
and behavior
interventions
Assesses progress
Handles requests for
psychiatric consultation
and other behavioral
health services
Utilizes supervision by
the consulting
psychiatrist
Coordinates care with
the primary care team
Participates in multidisciplinary education
and quality
improvement
Provides documentation
to support grants and
payment initiatives
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Consulting Psychiatrist
Clarifies the diagnosis
Guides medication
choice and use
Recommends lab
monitoring
Informs therapy
choices
Advises about
community
referrals
Assures process and
outcome
measurement
Attends systematic
case review sessions
Supervises BHC
Supports and
educates
the primary care
team
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Connects with
treatment programs
and facilities when
needed
Cooperates with
quality assurance and
cost containment
initiatives
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Primary Care Workflow
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Integrated Care Workflow
Behavioral Health Agency
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?
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Potential Connections between the Primary Care Team
and Behavioral Health Clinicians
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Frequency of
Contact
Method of
Contact
• after intake
and discharge
• if lost to
follow-up
• during
transitions of
care
• every visit
• record
release
request
• consult
report (fax or
HIE)
• phone
discussion
• curbside
Detail Provided
• appointments
kept
• clinical
summary
(diagnoses,
meds, test
results)
• care plan
Collaboration
• case review
• case
conference
• shared care
plan
• shared
decisionmaking
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Strategies to Improve Availability of Scarce Behavioral
Health Resources
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Optimize
Care
Integrated primary care team provides most services for
depression and anxiety directly with evidence-based,
stepped care and consultant back-up
Reduce
Waste
Care coordination maintains focus and continuity of
care, preventing wasted resources
Reduce
Demand
Self-management skills and supportive social services
prevent or moderate life crises
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Integrated Care Workflow
Sustainability and Continuing Assistance
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Care Coordinator Creates a Relapse Prevention Plan
with Patients once Targets are Sustained
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Telephone and in-person (typically, the relapse
prevention plan visit is in-person)
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Why is Self-Care Support Necessary?
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Peer Support
Patient Champions
Support Groups
• Persons who have dealt with
certain diseases or situations
successfully who are willing to
share information and provide
support to patients with similar
conditions
• Training in chronic care support
groups, care giver, or peer
specialist programs is desirable
• Community- or practice- based
groups that meet at least
monthly to provide information
and support around selfmanagement of chronic
conditions
• Leadership by health
professionals or trained lay
advocates is necessary
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Certified Peer Specialist
Is trained and certified
to provide support
services for mental
health recovery
Has a lived experience
of serious mental illness
and active recovery
Reinforces positive
strengths and behaviors
Provides selfmanagement education
and assistance with
health system
navigation
Teaches coping and
problem-solving
strategies
Empowers peers to
engage in goal setting
and personal
development
Works with persons
experiencing serious
mental illness
Supervised by mental
health professional
weekly
Utilizes SAMHSA Eight
Dimensions of Wellness
recovery model
Able to work in diverse
cultural and
environmental
circumstances
Case load of 20-25
individuals
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Referral
Networks
Care linkages and outreach
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Directories
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Specialized Resources
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Community Organizations
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Sustainability
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Optimized
coding
• MD-DO: 99213+99202 < 30%
• Chronic Care Mgmt. 99490, 99487, 99489
• SBIRT G0442, G0443
• Annual PHQ-9 screening G0444
• Telemedicine GT codes
• BHI Codes (GPPP1, GPPP2, GPPP3, and
GPPPX) in 2018
Pay-forPerformance
and MACRAQPP
• Depression screening, treatment and
response
(NQF 0104, 0105, 0418, 0710, 1365, 1885)
• Alcohol, tobacco, ADHD, etc. (NQF 0004,
0028, 0108)
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The Collaborative Care Model Saves Money
Improving Mood-Promoting Access to Collaborative Treatment (IMPACT)
No savings first year
• 12-month IMPACT
intervention cost of
$522 to $597 per
patient.
Second year savings for
IMPACT patients with
depression and diabetes
• Healthcare costsavings of $896 per
IMPACT patient with
depression and
diabetes over 2
years.
Third and fourth year
savings for IMPACT
patients
• 4-year cost-savings
of $3,363 per
IMPACT patient.
Unützer, JAMA, 2002; Katon, Diabetes Care, 2006; Unützer, J Manag Care, 2008
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Building Blocks
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Identify practice
aspirations and
drivers
Train and
reinforce patient
engagement skills
Clarify resources
available
Prepare staff,
clinicians, and
data systems
Map out work
flows and roles
Formalize external
care supports
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Module 1: Addressing Behavioral
Health in Primary Care
Across insurance types…
• Per member per month
without BH diagnosis = $397
• Per member per month with
BH diagnosis: $1,085
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Module 2: Building Internal
Capability
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Create a problem solving culture
Build a care team and redesign workflow
around Collaborative Care Model
Engage patients
Screen for behavioral health issues
and treat to target
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Additional Resources
http://www.integration.samhsa.gov/integrated-care-models/Behavioral_Health_Integration_and_the_Patient_Centered_Medical_Home_FINAL.pdf
Connects PCMH efforts and behavioral health integration for primary care settings.
https://www.thinglink.com/channel/622854013355819009/slideshow
The SAMHSA-HRSA quick guide to integrated care – encyclopedic in scope
https://aims.washington.edu/collaborative-care/implementation-guide
Collaborative Care Management is the evidence-based approach for complex patients in primary care.
http://www.cdc.gov/ncbddd/fasd/documents/alcoholsbiimplementationguide.pdf
SBIRT is the evidence-based approach for alcohol misuse in primary care.
https://www.qualitymeasures.ahrq.gov/search/search.aspx?term=depression
Regardless of what model you select for integrating care or to what extent you integrate care, it is critical to incorporate measurement and data-driven
QI into the care process and into the implementation process.
http://www.safetynetmedicalhome.org/change-concepts/organized-evidence-based-care/behavioral-health
A highly practical and field tested approach from leaders in the field.
www.motivationalinterviewing.org
A thoughtful and reliable source of information and resources.
http://dhss.delaware.gov/dhss/dhcc/files/healthyneighborhoods.pdf
The DCHI blueprint for state health innovation project.
http://dhss.delaware.gov/dhss/dhcc/files/careintegration.pdf
The DCHI vision and strategic approach for behavioral health integration.
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Bruce Block, MD
[email protected]
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