Download Integrated Care: A MeHAF Project

Integrated Care:
A MeHAF Project
WHEN THE HEAD IS ATTACHED TO THE REST OF THE BODY
Kathleen L. Webster RN, MSN PMHNP-BC
MEHAF GRANT
• MaineGeneral ACT TEAM selected to
participate in a 3 year Grant funded
project with the Maine Health Access
Foundation (MEHAF)
• MEHAF’s Mission:
• Promote affordable and timely access to
comprehensive, quality health care
• Improve the health of Maine residence
MeHAF GRANT
• Systems transformation grant
• Jan 1/09-Dec/11
• ACT TEAM one of 6 community
agencies selected
• Focus of grant-consumers with DX of
SMI in addition to diabetes or
metabolic syndrome
6 Community Agencies
• Common Ties
• Crisis and Counseling
• Kennebec Behavioral Health
• MaineGeneral ACT TEAM
• Motivational Services
• Tri-County ACT TEAM
MeHAF GRANT
• Key Objectives:
• Link consumers to PCP
• Care Management for consumers with SMI and
chronic medical diseases
• Peer Support systems enhanced or developed
• Develop screening tools
• Develop Tracking systems for clinical workflow
• Training and education for both consumers and
providers
• Communicate and collaborate with policy makers
MaineGeneral ACT Team Members
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The ACT TEAM CLIENTS
Emilie Van Eeghen
Barbara Crowley
James Schneid
Nancy Weingarten
Susan Albano
Jessica Ruth
Louise Gephart
Nina Miller
Louisa Barnhart
Maria Beauregard
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Amy McKenna
Debbie McGuire
Marc Gallant
Susie Carlsen
Jane Cloutier
Renee Quirion
Georgette Roy
Sheila Worth
Heidi Little
Stacie Dennett
Kathleen Webster
Target Population
• MaineGeneral ACT Team
93-100 persons who are cared for by the ACT
team in Augusta and Waterville participated in
this grant project over a 3 year period.
ACT team clients by definition have a severe and
persistent mental illness as well as co-morbid
substance use disorders and chronic medical
illnesses.
Significance of Clinical problem
• People with SMI die 25 years earlier
than people without SMI
• Average age of 53 years old
• A Maine Study of Medicaid Recipients
revealed 87% of lives lost to
premature death are not due to
suicide but rather chronic medical
conditions
Maine CDC 2004
SMI & Non SMI MaineCare
Maine CDC 2004
Utilization of Services
Maine CDC 2004
Diabetes & SMI- MaineCare
SMI -$5,360
• NON – $3,930
• Double the prevalence
• High risk – Smoking, Obesity,
dyslipidemia
• Less Access to a medical home
• Poorer Outcomes
Maine CDC 2004
Body-Mind-Spirit
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Hypertension
Diabetes
Obesity
Cardiovascular Disease
Access to primary and specialty care often hampered
Poverty
Substance Use/Dependence inclusive of nicotine
Poor Nutrition
Inadequate exercise
Exposure to psychotropic medications
Stigma
Socially marginalized
Support System often limited to care providers
Disconnect between mental health and physical health care
systems
IOM:
6 AIMS for IMPROVEMENT
• SAFE
• EFFECTIVE
• PATIENT-CENTERED
• TIMELY
• EFFICIENT
• EQUITABLE
• IOM, 2001
IOM:
10 RULES for REDESIGN
• Care is based on
continuous healing
relationships
• Care is Customized to
patient needs & values
• Patient is the source of
control
• Knowledge is shared &
information flows
freely
• Decision making is
evidence based
• Safety is a system
property
• Transparency is
necessary
• Needs are anticipated
• Waste is continuously
decreased
• Cooperation among
clinicians is a priority
• IOM, 2001
IOM:
4 Areas of Redesign
• Evidence Based Care
• Utilization of Information
Technology
• Aligning Payment Policies with QI
• Preparing the Workforce
•IOM, 2001
ACT Team
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MaineGeneral ACT Team
Approximately 93-100 persons who are cared for
by the ACT team in Augusta and Waterville
participated in this grant project over a 3 year
period.
COMORBID ILLNESSES
ACT TEAM COMORBID RATE
ED VISITS 12/09-11/11
Data
A Run Chart was utilized to study one outcome
related to ED usage.
Time studied was 12/09-11/11 representing 24
data points representing time.
The Number of ED visits by ACT team clients per
month was manually counted and plotted against
the time variant.
Data: Analysis & Interpretation
• Test #1 Presence of too much or too little variable
• There are 24 data points, excluding 1 point on the median, in which there
are 9 runs. The probability table shows that with 24 points at least 8 runs
are needed and no more than 17 therefore no special causes are present
only common cause.
• Test #2 Presence of a shift in the process
• There are no runs with more than 4 data points, at least 8 are necessary to
demonstrate a shift in the process therefore common cause only present
• Test #3
• No evidence of a trend as there are no more than 4
consecutive data points
Data: Analysis & Interpretation
• Common Cause Variation in the number of ED visits.
• This number of visits is worthy of a change process for
improvement
• NOTE addition of 4 hours per week of FNP starting in July
with an increase in communication and expectation of
collaboration between the ACT team clinical/support
staff and the PCP clinical and support staff.
Chronic Care Model
• Community
• Resources and Policies
• Health System
• Self Management
• Delivery System Design
• Decision Support
• Clinical Information Systems
• Productive Interactions
• Informed, Activated Patient
• Prepared, Proactive Practice Team
• Outcomes
• Improved Outcomes
Safe: Avoid injuries to patients from the care that
is intended to help them
Treatment Evidence Based
Labs as per recommended protocols
F/U w/ Psych Providers- Case Managers
F/U w/ Medical Providers- Case Managers
Avoid ED utilization as an intervention for
Primary care needs – Access to PCP key
Effective: Provide services based on scientific
knowledge to those who would benefit - refrain from
those not likely to …..
• One goal - to develop ways to
track health issues and workflow
• Development of a Screening Tool
• Request report from
MaineGeneral system related to
ED visits
PATIENT CENTERED: Respectful and responsive
to individual needs/values that guide the care
The 4 Quadrant Clinical Integration Model
Quadrant I BH PH
>PCP (screening tools & BH
practice guidelines)
>PCP based BH
consultant/care manager
>Psychiatric Consultation
Quadrant III BH PH
>PCP (screening tools/BH
practice guidelines)
>PCP based BH consultant/care
manager
>Specialty Med/Surg
>Psychiatric consultation
>ED
>Med/Surg Inpatient
>Nursing Home/Home based
care
>Community Resources
samhsa.gov 2010
4 Quadrant Clinical Integration Model
Quadrant IV
BH PH
>PCP (screening tools /
guidelines)
>Outstationed medical provider
in the BH site
>BH Clinician/case manager
>External Care Manger
>Specialty med/surg
>Specialty BH
>Residential BH
>Crisis/ED
BH/Med/Surg Inpatient
>Community Supports
Quadrant II
BH PH
>BH Clinician/CM coordinating
with PCP
>PCP (Screening
tools/guidelines)
>Outstationed medical provider
at BH site
>Specialty BH
>Residential BH
>Crisis/ED
>BH Inpatient
>Community Supports
samhsa.gov 2010
Timely and Efficient
Tracking of consumers who access ED to notify provider in real
time.
Linking the screening tool to Clinical support tools
Consumer Access of training options
System that would notify team of pertinent thresholds
labs
BMI
latest f/u per treatment guidelines
Diabetes Screening and Treatment
Recommended Labs
eye exams
foot exams
Equitable: care that does not vary in quality
due to gender, ethnicity, geographic location,
socioeconomic status
Linking consumer to a welcoming PCP one of the
primary intents of the MeHAF project.
• At the end of the 3 year project
• 100% of clients reported having a PCP
• 80% reported having seen PCP in past year
• 69% reported ED visit
OUTCOMES
Health Screen
• Developed in the Second Year of the Project
• Has increased the dialogues between team members, both
clients and staff.
• Has established some baseline data that is now informing the
practice in the office.
• Has created an opportunity for improved care outcomes
• Has created an opportunity for integrated care concepts
Health Screen
• Of 81 clients surveyed in the past 2 years
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53% have 5 or more co-morbid medical illnesses
15% have 4
14% have 3
11% have 2
7% have 1
2% have none documented
4 people have passed away in the past 15 months
Health Screen
• In the first 12 months
• 69 clients screened
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59% had BMIs > 25
38% had BP > 130/80
96% had a PCP
86% seen in past 12
months
• 44% seen in the ED for
both mental health and
medical care
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The following 9 months
64 clients screened
61% had BMIs >25
25% had BP> 130/80
• 100% had a PCP
• 80% seen in past 12
months
• 69% seen in the ED for
both mental health and
medical care
Take Away
• The dialogue with the client regarding their physical as well
as mental health concerns increased in frequency and
structure
• A richer base for patient education was established
• An increase in collaborative dialogues with health care
providers in the community who are also caring for the ACT
client
• An opportunity to have an FNP 4 hours per week in the ACT
team office as a result of dialogues with leadership bringing
us closer to an Integrated Care Model
Next Steps
• Formally establish health education groups in addition to 1:1
delivery of patient education
• Establish a physical health group (2nd Y-Group started 2/12)
• Increase FNP time at the ACT team office site to enable care
for both Waterville as well as the Augusta Case Load
• Continue to work on the Integrated Care Model as many
clients see this as their medical home
Bibliography
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Bodenheimer, T., Wagner, E. H., & Grumbach, K. (2002). Improving primary care for patients with chronic
illness. JAMA, 1775-1779.
Coleman, K., Austin, B. T., Brach, C., & Wagner, E. H. (2009). Evidence on the chronic care model in the new
millennium. Health Affairs, 28(1), 75-85.
Colton, C. W., & Mandersheid, R. W. (2006, April 05). Congruencies in increased mortality rates, years of
potential life lost, and causes of death among public mental health clients in eight states. Retrieved from
http://www.cdc.gov/pcd/issues/2006/apr/05 0180.htm
Dutta, T. (2010, October 21). Retrieved November 15, 2011, from SAMHSA: http:www.samhsa.gov
Freeman, E. (2009). The Poor Health Status of Consumers of Mental Health Care the Interaction of Behavioral
Disorders and Chronic Disease. Department of Health and Human Services. Augusta.
Freeman, E., Presley-Cantrell, L., Edwards, V. J., White-Cooper, S., Thompson, K. S., Sturgis, S., & Croft, J.
(2010). Gathering partnerships to bridge gaps among mental health, health care and public health. Preventing
Chronic Disease, 1-7. Retrieved Nov 05, 2011, from http://www.cdc.gov/pcd/issues/2010/jan/09_-127.htm
Institute of Medicine, Committee on Quality of Health Care in America. (2001). Crossing the quality chasm: a
new health system for the 21st century (executive summary).
Murphy, J. (2011). Patient as center of the health care universe: a closer look at patient-centered care. Nursing
Economic$, 35-37.
Wagner, E. H., Austin, B. T., Davis, C., Hindmarsh, M., Schaefer, J., & Bonomi, A. (2001). Improving chronic
care: translating evidence into action. Health Affairs, 64-78.
Weinstein, L. C., Henwood, B. F., Cody, J. W., Jordan, M., & Lelar, R. (2011). Transforming assertive community
treatment into an integrated care system: the role of nursing and the primary care partnerships. Journal of the
American Psychiatric Nurses Association, 64-71.