INTEGRATED CARE MODELS FROM THE GROUND UP: SUCCESSFUL STRATEGIES AND OUTCOMES OCTOBER 28, 2015 Debbie Innes-Gomberg, Ph.D. Lezlie Murch, MA, LPCC Mariko.

INTEGRATED CARE MODELS FROM THE GROUND UP: SUCCESSFUL STRATEGIES AND OUTCOMES

OCTOBER 28, 2015

Debbie Innes-Gomberg, Ph.D.

Lezlie Murch, MA, LPCC

Mariko Kahn, LMFT

Mental Health Services Act Innovation Project on Integrated Care• 3 year partnerships between 24 mental health agencies,

substance use programs and Federally Qualified Health Centers (FQHCs)

• 3 distinct models:• Integrated Clinic Model (ICM) 5 providers

• Integrated Mobile Health Team (IMHT) 5 providers

• Integrated Services Management for Underserved Ethnic Populations- 14 providers• African/African American• Native American• Asian Pacific Islander• Latino• Middle Eastern/Eastern European

Learning Goals• Determine what models are most effective in creating

integrated care and for which populations• Determining whether utilizing culturally relevant

engagement strategies improves access to care

Clients ServedModel Unique

Clients Served

A/AA Latino API AI/NA

ME/EE

W O/Mixed

ICM 1,408 20% 45% 2% <1% <1% 28% 4%

IMHT 581 45% 10% 2% 2% <1% 34% 6%

ISM 1,776 24% 36% 15% 8% 16% 1% <1%

Overview of Client Measures # of

ItemsCollection Frequency

Goal(s) Addressed

PROMIS Global Health 10 Quarterly Improved physical health outcomes Improved mental health status Successful links to integrated health care

PROMIS-derived Alcohol/Substance Use

12 6 months Successful links to integrated health care

Physical Health and Behaviors Survey

39 6 months Successful links to integrated health care Improved utilization of community resources Decreased use of emergency services (physical or mental) Culturally sensitive/competent care

CHOIS Supplement 20 6 months Positive Recovery Factors Specific Psychiatric Symptoms Response Inconsistency

Stigma Survey-10 10 6 months

Reduction in General Mental Health Stigma

ClientSatisfaction Questionnaire

10 6 months Culturally sensitive/competent care Client satisfaction with services Improved quality of care received

Post-Outcomes Survey 10 6 months Improved physical and mental health outcomes Improved community support Increased consumer self-efficacy

Overview of Clinician Measures # of

ItemsCollection Frequency

Goal(s) Addressed

Physical Health Indicators

10 6 months Improved physical health outcomes

Illness Management& Recovery Scale (IMR)-Clinician Version

18 Quarterly Community improvement/integration into the community Improved quality of care received by client Improved quality of care given by Clinician/Staff Improved mental health outcomes Successful links to integrated health care

Milestones of Recovery Scale (MORS)

1 Quarterly Improved mental health outcomes Increased involvement in care

Staff Satisfaction Questionnaire

TBD 6 months Culturally sensitive/competent care Improved quality of care given by Physician/Staff

Level of Service Integration• Integrated Treatment Tool (ITT)

• 3 Domains• Organizational• Treatment• Care Coordination

• Semi-structured interview conducted via a site visit• Utilizes a 5 point Likert scale• Measured during the first year of the project and with a phone

interview 1 year after the initial site visit

Integrated Treatment Tool:Ratings by Model

2.13

3.06

3.49

2.23

3.18

3.53

2.38

3.26

3.17

0 1 2 3 4 5

ISM

ICM

IMHT

IT Domains by Model

Organizational

Treatment

Care Coordination

JustBeginning

On the Way

FullyIntegrated

Integrated Treatment Tool:Organizational Domain by Model

0 1 2 3 4 5

Policies & Procedures

Organizational Training

CQI

Information/Technology

Care Manager

Interdisciplinary Communication

Peer Supports

Clinicial Supervision, Guidance & Monitoring

Integrated Approach

Patient Access & Scheduling

Executive Leadership Team Involvement

Patient-Centered Approach

Organizational Philosophy

Multidisciplinary Approach

Organizational Characteristics by Model

IMHT (n=5)

ICM (n=5)

ISM (n=14)

JustBeginning

JustBeginning

On the Way

FullyIntegrated

Integrated Treatment Tool:Treatment Domain

Integrated Treatment Tool: Care Coordination Domain

Successful Model Outcomes• All 3 models were successful in improving health, mental

health and substance use symptoms• There were no differences in improvements in health

status and mental health status across models• In both ICM and IMHT, the more highly integrated models

had poorer health status at baseline, and in general, greater improvements in health status

• Successful programs had staff that were willing to expand their professional roles in order to improve care (whatever it takes approach)

13

Measuring Client Recovery• Paired samples t-tests and chi-square tests were used to

examine the statistical significance of changes in scores on the measures over time

• Clinical significance is determined using the Minimal Important Difference (MID), which represents the smallest improvement in a scale score that would indicate an observable change in client health • If the difference between a client’s baseline and follow-up

scores on a specific outcome measure is greater than the MID, that client is considered to have achieved a clinically meaningful change for that outcome

• Both Statistical Significance and Clinically Meaningful Changes are reported

ICM Mental Health Outcomes

3.30

2.64

3.31

2.47

3.38

2.40

3.30 (N=865)

2.81 (N=683)2.65 (N=565) 2.64 (N=432)

2.52 (N=353)

2.51 (N=249)

2.48 (N=174)

2.54 (N=68)2.71 (N=29)

1.00

2.00

3.00

4.00

5.00

1 2 3 4 5 6 7 8 9

Assessment Number

ICM Overall IMR Scores

Assessment 1 vs 3 (424 Clients) Assessment 1 vs 5 (248 Clients) Assessment 1 vs 7 (121 Clients) All Clients

• There were significant improvements on the IMR, a clinician-rated mental health measure, 6,12 and 18 months after enrollment in INN services, compared to ratings at baseline

• The majority of ICM clients had clinically meaningful improvement in Overall IMR scores 6 months (71.0%), 12 months (79.4%) and 18 months (81.8%) after enrolling in services

ICM PROMIS Physical Health

• There were significant improvements in client-rated physical health outcomes 6,12 and 18 months after enrollment in INN services, compared to ratings at baseline

• Close to half of ICM clients had clinically meaningful improvement in PROMIS Physical Health scores 6 months (40.7%) and one year (39.9%) after enrolling in services, compared to baseline

3.19

2.96

3.24

3.00

3.29

3.143.12 (N=751) 2.99 (N=526)

2.95 (N=471)

2.92 (N=363)

2.99 (N=306)

2.98 (N=209)

3.05 (N=153)

3.00 (N=50) 3.13 (N=19)

1.00

2.00

3.00

4.00

5.00

1 2 3 4 5 6 7 8 9

Assessment Number

ICM PROMIS Physical Health Scores


ICM Use of Emergency Service

21.8%25.1% 25.9%

53.2%49.1%

52.9%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

Assessment 1 vs 3(312 Clients)



Clinically Meaningful Improvement Maintain 'No Emergency Room visits in past 6 months'

There was a significant decrease in use of emergency services 6,12 and 18 months after enrollment in INN services, compared to baseline

Of those clients that reported visiting the emergency room prior to receiving Innovation services, 25% of these clients reported fewer visits at the 18 month assessment

IMHT Mental Health Outcomes

• IMHT clients had significant improvements on the IMR, a clinician-rated mental health measure, 6 and 12 months after enrollment in INN services, compared to ratings at baseline. Clients continued to significantly improve between 12 and 24 months after first receiving INN services.

• The majority of IMHT clients had clinically meaningful improvement in Overall IMR scores 6 months (65.4%) and 12 months (74.9%) after enrollment.

3.60

3.07

3.57

2.84

2.81

2.52

3.61 (N=450)

3.23 (N=426)

3.09 (N=423)

3.01 (N=352)

2.93 (N=322)

2.78 (N=272) 2.66 (N=215) 2.60 (N=164)

2.53 (N=85)

1.00

2.00

3.00

4.00

5.00

1 2 3 4 5 6 7 8 9

Assessment Number

IMHT Overall IMR Scores


IMHT PROMIS Physical Health

• There was a significant improvement in client-rated physical health 6 and 12 months after enrollment in INN services, compared to ratings at baseline

• 52.7% of IMHT clients had clinically meaningful improvement in PROMIS Physical Health scores 6 months after enrolling in services, and over half of clients (52.7%) had clinically meaningful improvements 12 months after enrollment when compared to baseline

3.40

3.153.40 2.98

3.15 2.95

3.36 (N=298)

3.19 (N=253)

3.14 (N=280)

3.10 (N=255) 3.08 (N=235)

3.16 (N=210)

3.09 (N=166)

3.05 (N=117)

2.90 (N=52)

1.00

2.00

3.00

4.00

5.00

1 2 3 4 5 6 7 8 9

Assessment Number

IMHT PROMIS Physical Health Scores


IMHT Use of Emergency ServiceThere was a significant decrease in use of emergency services 6 and12 months after enrollment in INN services, compared to baseline

Of clients who had visited the emergency room prior to receiving Innovation services, the percentage of clients with fewer ER visits increased during each subsequent assessment period during the first year

37.4%41.7%

15.6%

24.6%

32.3%

64.4%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%




Clinically Meaningful Improvement Maintain 'No Emergency Room visits in past 6 months'

IMHT Impact on Homelessness

• Compared to baseline, IMHT clients spent significantly fewer days homeless 6 and 12 months after enrollment in INN services.

• Many IMHT clients (40.1%) reported a clinically meaningful reduction in the number of days spent homeless 6 months after enrolling in services, when compared to baseline.

• More IMHT clients (69.9%) experienced a clinically meaningful reduction one year after enrollment in IMHT.

171 days

114 days

172 days

57 days

44 days

39 days

165 days (N=384) 114 days (N=285)

60 days (N=229)

38 days (N=184) 35 days (N=67)

0

20

40

60

80

100

120

140

160

180

1 2 3 4 5 6 7 8 9Assessment Number

IMHT Number of Days Spent Homeless


ISM Mental Health Outcomes

• ISM clients had significant improvements on the IMR, a clinician-rated mental health measure, 6 and 12 after enrollment in INN services, compared to ratings at baseline

• The majority of ISM clients had clinically meaningful improvement in Overall IMR scores 6 months (73.1%) and one year (76.2%) after enrolling in services

3.25

2.65

3.27

2.51

3.27 (N=1341)2.85 (N=1042)

2.66 (N=822)2.54 (N=582) 2.51 (N=386)

1.00

2.00

3.00

4.00

5.00

1 2 3 4 5Assessment Number

ISM Overall IMR Scores

Assessment 1 vs 3 (733 Clients) Assessment 1 vs 5 (341 Clients)All Clients

ISM Constructive ActivitiesISM clients reported a significant increase in paid employment 6 and 12 months after enrollment in INN services. 23.7% of ISM clients reported that they maintained paid employment for the first year of services; 10.7% of ISM clients gained employment within the first year of services

% Engaged

Baseline (All Clients N=1175) 27.0%

Assessment 1 vs. 3 (596 Clients) 27.0% vs. 32.4%

Assessment 1 vs. 5 (270 Clients) 28.9% vs. 34.4%

During the past 6 months, which of the following have you done?

Have paid employment?

% Engaged

Baseline (All Clients N=1172) 18.3%

Assessment 1 vs. 3 (596 Clients) 15.8% vs. 19.0%Assessment 1 vs. 5 (270 Clients) 15.9% vs. 15.6%

Attend school?

Significantly more ISM clients reported attending school 6 months after enrollment, compared to baseline. 11.1% of ISM clients reported that they maintained engagement in school for the first 6 months of services; 7.9% of ISM clients began attending school within 6 months after enrollment

Effecting Positive OutcomesPartnerships: Through the lense of the Provider:• Establish intentional partnerships, clear purpose and service

expectations • Partnership development as a longer term strategy or

investment to develop integrated care• Utilize team meetings as a way to initiate or enhance

integrated care• Establish a culture of collective investment in patients

Partnerships: Through the lense of DMH:• Conduct regular implementation team meetings to ensure

strong communication, problem-solve and involve the evaluator• Establish a balanced role between provider monitoring

(compliance) and facilitating partnerships and learning

Effecting Positive Outcomes

Establish a culture of learning and support • Establish concrete learning structures that facilitate communication

and experimentation• Engage in active, collaborative problem solving• Promote synergistic learning• Utilize outcome data to ground learning

Effecting Positive Outcomes• Build on existing models of care (Assertive Community

Treatment)• Emphasize the collection and use of outcome measures

and promote data driven management• Strategic use of data improved over time • Fund infrastructure development to support integrated

care• Fund care coordination, including shared care planning

and review

The Evaluation Rubric By Model

Client Level (60%) IMHT ICM ISM

Quality of Care 59% 59% 40%

Quality of Life 34% 34% 40%

Client Satisfaction 7% 7% 20%

Program Level (40%)

Data Compliance 15% 10% 11%

Access to Care 30% 25% 26%

Staffing 16% 12% 6%

Cost 0 % 24% 0%

Integration 22% 17% 26%

Outreach and Engagement 17% 12% 31%

SAMHSA Center for Integrated Health Solutions (CIHS) Framework• 5 levels from minimal collaboration to close collaboration

in a fully integrated system, sharing a location, vision and a system. • Coordinated ----------- Co-Located------------- Integrated Care • In-depth appreciation for role and culture of each organization• One plan, one team for one client• Intentional planning

Exodus Recovery Integrated Care Models

SUCESSFUL STRATEGIES

WITH A FOCUS ON:

• Organizational Structure

• Treatment Design

• Care CoordinationBy Lezlie Murch, MA, LPCC

Sr. Vice President, Programs

Exodus Recovery/Exodus Foundation

Organizational Strategies• Organizational Philosophy – Exodus chose to partner with

a physical health FQHC and a supportive housing developer whose mission and philosophy was closely aligned with our own - to take care of vulnerable, mentally ill individuals with complex needs

• Los Angeles Christian Health Centers and Skid Row Housing Trust were enlisted in INN program design, development and implementation from the RFP process forward. This served to build trust and communication among leadership staff that set the tone and formed the foundation for success

• This solid foundation of collaboration led to shared decision making AND effective interdisciplinary communication between staff

• Mental health and physical health services appear seamless to clients• Truly integrated, collaborative service delivery produced client centered,

positive outcomes

Organizational Strategies in Operation

• Executive Leadership Teams meet monthly to discuss progress and share successes

• Policies and Procedures written specifically for integrative care• Outcome data is shared with all staff to shape clinical practice• Clinic design encourages flow of communication• Mobile Team deploys together daily in the Exodus van• Morning team meetings with all staff, every day• Mental health and physical health providers frequently see

clients together to promote transparency and collaboration• A integrated, shared medical record encourages effective

communication and best practices

Treatment Design Strategies• All multidisciplinary staff and partners are oriented and

trained at Exodus by the ERI Leadership team and at DMH to promote education, consistency in treatment approach and philosophy and team building

• All service interventions are designed around our specific target population in collaboration with interdisciplinary team partners

• Exodus collaborates with FQHC and Housing Developer partners to develop integrated assessments for clients thus reducing redundancy

• Regular integrated team conferences build clinical confidence and promote innovative thinking

Treatment Strategies in OperationIntegrated Mobile Health Team

• IMHT - Outreach and engagement specifically designed for high risk, homeless and complex mentally ill individuals

• Early Morning shifts (3:30AM) at homeless encampments• Participating in numerous O&E activities with other community agencies• Enlisting the aid of homeless “Ambassadors” on skid row and within shelters• Distributing coffee, clothes, water and soap and food to build trust and

rapport with homeless

• Team utilizes EBP’s such as Motivational Interviewing and Harm Reduction to meet the client where they are

• IMHT Team practices “no wrong door” when engaging clients• Team promotes skill building, self management and

independence through effective pharmacology and individualized integrated care plans

Treatment Strategies in OperationIntegrated Clinic Program

• Staff create a welcoming & safe environment for clients and staff

• Daily consult with interdisciplinary team on clients’ integrated treatment & menu of services

• Specific interventions designed around clients complex medical needs

• Group content developed in collaboration with clients and families – healthy living and prevention as well as EBP’s such as Seeking Safety, Anything Anonymous

• Individual appointments are conducted with clients and/or families to address issues related to health education, medication, adherence to treatment, nutrition, exercise, etc.

• Staff develop health-promoting resources in the community

Care Coordination Strategies• Staff work to develop a culturally competent method to ensure

the client’s ACCESS to primary and behavioral health care/ SA Services in accordance with an integrated treatment plan

• Staff assist in the transition of care from one setting to another: (hospital, respite care, SUD treatment, SNF, Board and Care) through effective communication with CBO’s

• Staff schedule appointments for specialty care and community based services and arrange transportation

• Staff connects clients to relevant community based services and provide a warm hand off

• Staff utilizes Coordinated Entry System (CES) for housing prioritization and matching and promotes housing retention through supportive services

The Impact of the Journey

Change implemented• Effective service delivery models adopted• Incorporated outcome data into practice• Use of data to make decisions- evaluation rubric• Identified culturally relevant approaches to engage and serve

specific under-represented ethnic populations

For More Information

Debbie Innes-Gomberg, Ph.D.

Los Angeles County Department of Mental Health

[email protected]

Lezlie Murch

Exodus Recovery

[email protected]

Mariko Kahn

Pacific Asian Counseling Center

[email protected]

mailto:[email protected]

INTEGRATED CARE MODELS FROM THE GROUND UP: SUCCESSFUL STRATEGIES AND OUTCOMES OCTOBER 28, 2015 Debbie Innes-Gomberg, Ph.D. Lezlie Murch, MA, LPCC Mariko.

Documents

integrated clinic model

mental health agencies

mobile health team imht

successful strategies

relevant engagement

underserved ethnic populations

lpccmariko kahn

substance use programs