Primary Care and Behavioral Health: Southcentral Foundation’s Integrated Approach Donna Galbreath | Senior Medical Director of Quality Assurance David Lessens | Medical Director 65,000 voices
Primary Care and Behavioural Health: Southcentral Foundation's Integrated Approach
Apr 12, 2017
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Primary Care and Behavioral Health: Southcentral Foundation’s
Integrated Approach
Donna Galbreath | Senior Medical Director of Quality Assurance David Lessens | Medical Director
65,000 voices
Vision A Native Community that enjoys physical, mental, emotional and spiritual wellness
Mission Working together with the Native Community to
achieve wellness through health and related services
Goals S hared Responsibility
C ommitment to Quality
F amily Wellness
Customer Ownership
Operational Principles
Core Concepts
Define Southcentral Foundation’s Nuka System of Care
Describe Southcentral Foundation’s Primary Care and Integrated Care Teams
Share Southcentral Foundation’s Behavioral Health Integration Journey
Objectives
Notecards Turn in your questions at break
Evidenced-based, generational change reducing family violence
36% drop in both ER visits and hospital admissions from 2000-2015
75-90 percentile on many HEDIS outcomes
Benchmarked data nationally and internationally showing top in class performance in utilization, quality and satisfaction
Employee turnover rate decreased 15% from 2007-2015
96% customer satisfaction and 95% staff satisfaction
Baldrige Award 2011
Why listen to our story
Alaska Native People Shaping Health Care
Alaska Native people chose to assume responsibility
We Changed Everything
Timeline
Planning Transition Implementation
The next big change and the
next big change…
Listen FIRST
The Start of Our Big Change Journey
• Governance
• Leadership
• Customer-owners
• Employees
• Other organizations
Operational Principle Alignment
Aligns • Un-blinded
performance data
• Defined PCP responsibilities
No alignment • Group visits
• Nurse Call Line
Some alignment • Disease specific
approaches
Culture of Improvement
Improvement Advisors and Specialists
Quality Management Courses
Committee Structure
Tools, methods and processes • E.g., Baldrige
Infrastructure to Support Improvement
Customer-owner drives the system • Shared responsibility
Leadership must support and drive
Access and relationship
Messaging is critical
Pay attention to workforce
Data matters
Process for change necessary • Never done, always willing to adapt
Lessons Learned
Empanelled customer-owners: Ensures continuity of care
Builds relationships
Creates trust between customer and team
Progress/healthy outcomes
Open access to Integrated Care Team
Email, phone, talking rooms
Continuity
Governance History at SCF
Owned and managed jointly by SCF and Alaska Native Tribal Health Consortium (ANTHC) on a Joint Operating Board
• 4 SCF Board Members
• 5 ANTHC Board Members
SCF Board of Directors delegates duties to the ANMC Joint Operating Board for the operation of the campus
Integrated Care
Clinical Operational
Financial Structural
20%
20%
10%
Clinical Workload Prior to System Redesign
Provider
Chronic
Disease
Monitoring
Preventive
Med
Intervention
Mental Health
Provider
Referral to
Specialist
after
Assessment
Medication
Refill
New Acute
Complaint
Certified
Medical
Assistant
Case
Manager
Test Results
Healthcare
Support
Team
Traditional Methods of Managing Workflow
Healthcare
Support
Team
Chronic
Disease
Monitoring
Preventive
Med
Intervention
Behavioral Health
ConsultantProvider
Medication
Refill
New Acute
Complaint
Certified Medical
Assistant
Case
Manager
Test
Results
Point of
Care
Testing
Acute Mental
Health
Complaint Chronic
Disease
Compliance
Barriers
Parallel Work Flow Redesign
Primary Care Provider (1,100-1,400 empaneled customers)
1 RN Case Manager : 1 PCP
1.5 CMA : 1 PCP
1 CMS : 1 PCP
1.5 Midwives : 6 PCP
1 BHC : 6 PCP
0.5 RD : 6 PCP
1 PharmD : 6 PCP
Integrated Care Team Ratios
It’s all about relationships
What Works for the Customer-Owner
Case Management Support
RN Case Manager
Dietician
PCP
Coverage NP/PA
CMA BHC
Integrated Care Teams
Provider
RN Case Manager
Traditional Case Manager
Whole Person Case Management
Case Management Support (CMS)
Certified Medical Assistant (CMA)
Behavioral Health Consultant
Integrated Pharmacists
Dietitian
Integrated Midwifery
Integrated Care Team Current Work
Health care provider changes No longer a hero but a
partner
Control does not equal compliance
Replace blaming with understanding
Give customer options, not orders
Provider customer with resources
Make it simple
Customer-owner changes Actively involved in partnership with your Primary Care Provider
Take responsibility for your health
Get information about your health
Ask questions about advice
Ask for options
Information to Knowledge % SCF Central Pharmacy customer-owners requesting other
medications at dispensing
0%
10%
20%
30%
40%
50%
8/5/10 8/12/10 8/19/10 8/26/10 9/2/10 9/9/10 9/16/10 9/23/10 9/30/10
Percent
Average
Better
Source: Central Pharmacy-Pharmacy t ic-sheet 9.27.10
Change
Tested
Change
Implemented
% Employees with Current Annual Disaster Tng
53
74
94 98 100
0
50
100
2005 2006 2007 2008 2009
%
SCF Industry Best (100%)
Visits to ED/Fast Track Combined per 1000 Member Months
Native ownership begins
1998
ED Visits per 1000 Member Months (2015 HEDIS 25th Percentile=50.68)
Native ownership begins
1998
79.9%
87.5% 84.1%
98.4% 100.0% 98.2%
71.8% 68.9%
66.9%
92.7% 87.5% 89.5%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
70.0%
80.0%
90.0%
100.0%
Cervical Cancer Breast Cancer Colorectal Cancer Diabetes Annual A1c Diabetes LDL for CVD BMI Assessed
Pe
rce
nta
ge
of
cust
om
er-
ow
ne
rs
Eligible Customer-Owners Who Received Screenings: Those on Wellness Care Plans (WCP) vs. those who are not
On WCP ------ HEDIS benchmark(75%) No WCP
Sustained Improvements
95 96 % Employee Satisfaction
% Customer Satisfaction
36 36 % Reduction
ER Visits 2000-2015
% Reduction Hospital Admissions
2000-2015
Break
Behavioral Health is woven into the fabric of all the care at SCF
Relationships & Greater Awareness
Physical-Behavioral Connection
Increased Access
Why Integrate Behavioral Health?
Behavioral and psychosocial factors in etiology and treatment of physical disease
Primary Care as the location of treatment for mental health disorders
Financial advantages
Improved quality of care
Customer and provider satisfaction
Illustrates Biopsychosocial model
Meets patients “where they are at”
Unifies medical and mental health practice
Stigma surrounding going to “mental health”
Benefits of Integration
Behavioral Health Consultants (BHC) integrated into primary care clinics 12 years ago
How are we meeting the needs of customer-owners?
First steps – we started small
Ongoing
SCF History of Behavioral Health Consultant (BHC)
Behavioral Health Integration What We Do
Medical Behavioral Specialty
Collaborative Care
Shared goals and vision, but no financial or operational infrastructure
Flexible communication
Recruiting/training
Orientation and training of primary care providers
Maintaining strong connection to behavioral health
Proximity
Charting
Level of consultation/referral
Operational
Behavioral Health Integration Key Elements
Communication Model
Approach to Care
What We Found
Cost Efficiency Time Efficiency
Access Job Satisfaction
Customers present with a range of concerns
Meet them where they are at
Help to improve their overall health
Ex: Customer presents with chest pain, medical rule out, focus on stress
Grief, situational stress, etc.
Work with specific subpopulations
Targeted interventions for these
populations
Define treatment protocols and clinical guidelines
Ex: Depression screening and follow-up
Two approaches to clinical work
Not Targeted Targeted
• Depression (PrimeMD)
• Substance Use (SBIRT, CRAFFT)
• Cognition (MMSE)
• Development (ASQ, ASQSE, M/CHAT, SDQ, Vanderbilt)
• Chronic Pain
Behavioral Health Integration What We Assess
Referral From Provider
Introduction & Negotiating Work
Assessment
Intervention
Follow up Phase
Feedback to ICT Members
Phases of Brief Intervention
Clinical Access
Depression
Anxiety
PTSD/Acute Stress
Childhood Behavioral Concerns
Parent Coaching
Substance Abuse
Grief
Sleep Hygiene
Traumatic Brain Injury
Psychosocial Stressors
Family/Relational Stress
Specific age related concerns
• Women’s Health
• Children
• Elders
Clinical Areas in an Integrated Primary
Care Setting
BHC Training
Pe
er
Sh
ado
win
g
Primary Care Provider Orientation & Training
Needs Assessment
PCP Challenges
PCPs had difficulty with limited consult time
Visibility in primary care clinic was difficult with full caseload
Due to limited visibility referrals for medication stayed the same for those PCPs and BHCs who were not sitting directly next to psychiatry
Understanding how to use consultation and integration
Implementing this model secondary to Behavioral Health Consultants
Adding on additional responsibilities/tasks
Supervision of BHCs
Psychiatric case reviews
Too many cooks in the kitchen and steps in the process vs. collaboration to meet C-O needs
BHC Challenges
PCP providers used consult time
Most consults routed through BHCs
C-O getting behavioral health services when they need it
Better relationships between primary care and behavioral health staff
Increased capacity of PCPs to provide behavioral health
Start small, learn from failures
What Worked for Us
Success Data
77% Primary Care Clinic staff reported increased efficiency
88% Primary Care Clinic staff are more satisfied with their job since BHC Integration
91% increase in access to behavioral health service
31,224 customer visits to BHCs in 2014
Outcome data coming . . . PHQ-9, trauma scale, etc.
Increased access, capacity, quality and satisfaction
97% Customer-Owner Satisfaction
12-17% Reduced no Show/DNKA rates
15% Consultation Encounters/FTE increased
1 week Wait times down from 6 to 1 week
Clinical Access
Support for Change
91% attendance
Data analysis from the National Council initiative shows customers offered a same day appointment show up 91% of the time
20% decrease
Customers are 1% less likely to show up for their assessment appointment for every day they have to wait Based on SCF data history: Wait time for Primary Care Clinic (PCC) Intake Assessment was approximately 4 weeks
Behavioral Services Co-location with Medical Services Primary Care
More consultations between Behavioral Health Consultants (BHC) and Primary Care Providers (PCP) with on-site Psychiatrists
Shared pool/population of Customer-owners cared for in cooperation w/ PCP’s
PCP’s receive clinical chart reviews and treatment guidance regarding behavioral health issues and medications
Increased access/capacity with reduced wait time
Enhanced Integration
Outpatient BHC’s working with children, youth and families need more time for brief intervention (up to 45 minutes compared to 30 minutes for a BHC seeing an adult)
Finding the right fit for the BHC can be a challenge, since they often have experience working as a traditional therapist and may apply that perspective
Our Customer-owners are seeing more MSD-BHC’s than previously known
BHC Lessons Learned
Who really makes the decisions?
Acuity
“Control”
0 Low High
100%
1. Control – who makes the final decision influencing outcome? 2. Influences – family, friends, co-workers, religion, values, money 3. Real opportunity to influence health costs/outcomes – influence on the choices
made – behavioral change 4. Current model – tests, diagnosis, treatment (meds or procedures)
Shared Responsibility
Questions?
Come Visit Us in Alaska!
Training Dates
Learning Circles: Bringing People Together Webinar
Dates available soon
June Conference June 19th-23rd, 2017
London and Manchester Nuka Masterclasses
Oct. 2nd-3rd, 2017
Nuka Health Care Innovation Conference - Oregon
Oct. 23rd-24th, 2017
www.scfnuka.com @SCFNuka [email protected] 907-729-Nuka (6852)
Contact Us:
Thank You!
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