Transcript Predict - Collaborative Family Healthcare Association

Session #D3
October 28, 2011
3:30 PM
Behavioral Health/Pediatric Primary
Care Integration at Geisinger:
Year 1 Implementation & Evaluation
Shelley Hosterman, PhD
Paul Kettlewell, PhD
Christine Chew, PhD
Tawnya Meadows, PhD
Collaborative Family Healthcare Association 13th Annual Conference
October 27-29, 2011 Philadelphia, Pennsylvania U.S.A.
Faculty Disclosure
We have not had any relevant financial relationships
during the past 12 months.
Need/Practice Gap & Supporting Resources
• Parents often bring their children to primary care
physicians first (Smith, Rost, & Kashner, 1995)
• 15% to 21% of primary care visits are for behavioral
health concerns (Kelleher, Childs, Wasserman, McInerny, Nutting,
Gardner, 1997; Lavigne, Gibbons, Arend, Rosenbaum, Binns, Christoffel, 1999;
Williams, Klinepeter, Palmes et al., 2004).
• During 50% to 80% of child health care visits, parents
or physicians raise concerns of behavioral or
psychosocial issues (Cassidy & Jellinek 1998; Fries et al., 1993; Sharp,
Pantell, Murphy, & Lewis, 1992).
Need/Practice Gap & Supporting Resources
Problems with seeking behavioral health services from PCP:
• Increased number of medical visits
• Increased time spent with the physician
• Lost revenue if a patient takes more time than scheduled
• Lower reimbursement rate for mental health issues
• Limited training in mental health treatment
(Connor, McLaughlin, Jeffers-Terry, O’Brien, Stille, Young, & Antonelli, 2006; deGruy,
1997; Leaf, Owens, Levelthal, Forsyth, Vaden-Kiernan, Epstein, Riley, & Horwitz,
2004; Strosahl, 2002; Young, Klap, Sherbourne, & Wells, 2001)
Need/Practice Gap & Supporting Resources
Problems with seeking behavioral health services from PCP:
• Decreased number of patients seen
• Increased risk of physician burnout
• Unsatisfied patients
• Increased impairment in patient health and functioning
• Increased use of acute and emergency care
(Connor, McLaughlin, Jeffers-Terry, O’Brien, Stille, Young, & Antonelli, 2006; deGruy,
1997; Leaf, Owens, Levelthal, Forsyth, Vaden-Kiernan, Epstein, Riley, & Horwitz, 2004;
Strosahl, 2002; Young, Klap, Sherbourne, & Wells, 2001)
Objectives
• Understand the collaborative development process
with the Geisinger Health Plan & Pediatric Partners
• Describe Geisinger’s pilot model
• Describe program evaluation plans for this project
• Review baseline data for the program
Agenda
• Developing the model – Process & Supports
• Details of pilot model
• Program evaluation & research
• Baseline data & future directions
Development: Previous System
• Outpatient mental health services, inpatient psychiatric
unit, & consultation/liason in major hospital
• 3 pediatric psychs, 1 family therapist, 1 psychiatrist, 3
pre-doctoral interns, & 2 postdoc fellows
• Serving all children/adolescent in 5 counties, all
patients with Geisinger PCPs, specialty patients
• Concerns with system: Waitlists, no shows, patient
travel, caseloads, problems recruiting psychiatrist
Development: Model Prototype
Munroe-Meyer Institute – Inspiration for our model
University of Nebraska Medical Center; Omaha, NE
http://www.unmc.edu/mmi/behavioral/
Joseph H. Evans, Ph.D.
Director, Psychology Department
Rachel Valleley, Ph.D.
Outreach Behavior Health Clinics Coordinator
Development: Model Prototype
• Behavioral health
services in primary care
• 23 outreach clinics
across Nebraska
• Reaching underserved,
rural populations
• Co-located &
collaborative clinics
• Interns/postdocs
trained in the setting
• Education for PCPs
• Frequent contacts
regarding referrals
• Research & program
evaluation
• Promising outcomes –
Discussed later
Development: Our System
Geisinger Health System • Integrated health network
• Serves 43 counties; 20,000 sq miles; 2.6 million people
• Nearly 60 community practice sites across the state
• System-wide electronic medical record
• Geisinger Health Plan – Among nation’s largest rural
HMOs (270,000 members)
Development: Marketing Change
Step 1: Approached psychiatry administration (10/09)
• Response – Excellent concept, but no way to proceed
within budget
Step 2a: Presentation at psychiatry grand rounds (2/10)
• Response – Excellent concept
• Possibility #1 – Private donor looking for a way to
support mental health of children/adolescents
• 2b: Private meetings & additional presentation to
private donor secured substantial gift
Development: Marketing Change
Step 3: Presentation to Pediatric Grand Rounds (03/10)
• Response – Pediatrics enthused & many requested
Step 4: Presentation to Geisinger Health Plan (Spring ‘10)
• Summary – Model offers better care, may save money,
& carve out model of payment does not make sense
• Response – We agree, what should we do?
• Key message – They believe is better care & will support
if we can break even or save money
Development: GHP Proposal
Monthly planning meetings with GHP administration
Data review process:
• Medical expenses for pediatric patients with ≥1 BH visit
double those of comparison patients
• Key cost differences: Outpatient, pharmacy, & ED
• Potential for cost off-set?
Outcome: GHP funded pilot project & program evaluation
Development: GHP Proposal
Proposal objectives:
1. Improve quality of behavioral health care
2. Reduce medical expenses & utilization of patients with BH
concerns
3. Increase physician, parent, & patient satisfaction with
service model & delivery
4. Expand PCP knowledge of BH assessment & intervention
5. Improve access, adherence, efficiency, & integrity of BH
services & intervention
Development: Task Force
• Key stakeholders
• Review problems & solutions in our system & state
• Information gathering & review of other models
• Focus on partnership, collaboration, & consultation to
help children & adolescents
• Electronic survey of primary care providers
Development: PCP Survey
Most common problems
•
•
•
•
•
ADHD (77%)
Obesity (72%)
Depression (57%)
Anxiety (47%)
Disruptive Behavior
(44%)
Most want training/assistance
• ADHD (45%)
• Disruptive Behavior
(43%)
• Anxiety (32%)
• Obesity (29%),
• Depression (26%)
• Eating Disorders (26%)
Development: PCP Survey
Barriers to service:
•
•
•
•
•
•
•
•
No local resources (94%)
Getting appt (55%)
Insurance issues (46%)
Travel for families (35%)
No time to address (24%)
No training (20%)
Patient Follow (11%)
No collaboration (11%)
•
•
•
•
Desired Models:
On-site services (76%)
Training in assessment &
diagnosis (65%)
Medication consults (64%)
Screening tools (49%)
Development: Task Force
Follow-up interviews with primary care:
• Additional input
• Assess site specific enthusiasm, barriers, and % GHP
• Identified three sites  Presented to CPSL
Three goals:
1. Behavioral health providers on-site in PCP sites
2. Support PCPs with screening tools & training
3. Case consultation with child/adolescent psychiatrist
Clinic Structure: Team Planning
• Team planning meetings – Psych & PCPs, office staff
• Shadowing PCPs
• Billing discussions
• REACH Institute training – PCPs & Psych’s together
– Focus on screening & psychopharm
Clinic Structure: Services
Report templates: Concise, completed during visit, structured
for brief review
Clinician schedules: 1 psychologist + 1 psychology fellow
• 75 min evals, 45 min returns
• 75% scheduled – Always available to PCP
Warm hand-offs & consultations:
• Join visits, education, pass patients on, simple
recommendations, immediate eval
• Tracking details
Clinic Structure: Services
Handouts – Common for psychologists & PCPs
Crisis evaluations as needed
Communication – Medical record & constant contact
Ongoing training for PCP’s
• Monthly case conferences
• Presentations on request
Relationship building – Join clinic community
Clinic Structure: Services
Common screening tools
Anticipate high-volume issues
• ADHD evaluations
• Weight management
• DBC groups
Psychiatry consultation – Case review & phone consultation
Electronic screening tools – Results directly in medical record
Clinic Structure: Services
Brief Case Examples
Program Evaluation: Key Domains
• Satisfaction
• Medication use
• PCP comfort/knowledge
in assessment &
intervention
• Utilization data
• Quality of life
• Quality of Care v. Practice
Standards
• Clinically significant
symptoms
• Clinic efficiency data
Program Evaluation: Tools & Predictions
Satisfaction: Pre & Post questionnaires for parents & PCPs
Includes:
• Convenience, time to first appointment, Stigma/Comfort
• Communication with PCP
• Perceived Benefit
Predict increased satisfaction relative to traditional model
Comfort and Knowledge: Physician survey
• Pre & post training, pre-integration, & yearly
Predict increases across each measurement
Program Evaluation: Tools & Predictions
Quality of Life: Peds QL-4
• Pre & post intervention
• School questionnaire – attendance, performance
• Predict improved QOL & school attendance
• Predict match results from other CBT outcome studies
Clinical symptoms: Target behavior ratings
• 5 point Likert Scale at every session
• Dual purpose - research outcomes & tracking treatment goals
• Most immediate/likely measure of change
• Predict steady reductions across course of treatment
Program Evaluation: Tools & Predictions
Medication use
• Chart review – Pre and post integration, per diagnosis
• Predictions – More appropriate use (sufficient trials,
monitoring change, appropriate match to symptoms)
Utilization data: Chart Review
• # Medical visits: Frequency PCP visits reduced pre v. post
• Specialist visits: Frequency reduced pre v. post
• Time to first visit – Reduced delay between physician referral
& assessment vs. traditional model in our system
• Out of network – Pre & post insurance company data. Predict
reduced out of network
Program Evaluation: Tools & Predictions
Efficiency data
• Time study: Pre, yearly, post
• Code: Medical, Beh, & Med/Beh visits
• Appointment duration: no change on medical appointments,
less time on behavioral & med/beh
Cost savings & cost effectiveness: Pre, yearly, post
• Predict increase in overall clinic revenue, reduced PMPM cost
for patients with BH issues
Quality of Care
• Identify AAP standards of care
• Chart review assessing adherence with standards
Time Study Data
Table 1
Minutes Spent Per Visit
Type of Concern
Percent of Total Visit
Types Observed
Mean
(N)
Medical
301
14.04
Behavioral
10
13.60
Medical and
Behavioral
34
12.99
Elimination
Disorder
Developmental
Disorder
ODD
Tic Disorder
Autism
Anxiety
Disorders
ADHD
Results
Percentage
10
9
8
7
6
5
4
3
2
1
0
Referral to Pediatric Psychology
• 2.9% of all patients observed were referred to
peds psych
• 28% of those diagnosed with a psychological
disorder were referred to peds psych
Baseline data: Referrals & Handoffs
Consults
Warm
Handoffs
New
Appointments
Return
Appointments
Crisis
0
Clinic 1
19
16
23
39
Clinic 2
23
31
59
36
6
Clinic 3
38
14
31
35
3
80
61
113
110
9
Total
Learning Assessment
Questions?
Session Evaluation
Please complete and return the
evaluation form to the classroom monitor
before leaving this session.
Thank you!
Contact Information
Shelley J. Hosterman, PhD
[email protected]
References available upon request