Transcript from the meeting. - Virtual Community for Collaborative Care

ACC Program
Best Practices
&
Clinical Transformation
Meeting
Wednesday, February 27, 2013
5:00 - 7:30 PM
ACC Program Best Practices and Clinical
Transformation Meeting Agenda
5:00 PM
Refreshments
5:15 PM
Integrating Behavioral Health into Primary Care Practice
Deb Parsons, MD
Medical Director, Region 3
5:30 PM
A Roadmap : Pediatric Primary Care and Behavioral Health Services
Integration
Lydia M. Prado, PhD; Yvette Buxton, MD; Dawn Wilson-Davenport, PhD; and
Rachel Lund, LCSW
The Mental Health Center of Denver
RMYC/MHCD Behavioral Health Integration: Provider Perspectives
Adjourn
Lori Cohn and Kim White, MD
Rocky Mountain Youth Clinics
Yvette Buxton, MD and Rachel Lund, LCSW
Mental Health Center of Denver
Additional Perspectives
7:30 PM
Adjourn
Upcoming Region 3 & 5 Meetings of
Interest
 March 20th: Information and Operations Meeting, NEW
TIME! 1:00 pm - 3:00 pm
 Colorado Access, Denver Highlands (Clock Tower) Building, 1st
floor, 10065 E. Harvard Ave., Denver, CO 80231
 May 7th: Colorado Access Performance Improvement
Advisory (Medical and Behavioral Quality Improvement)
Committee Meeting, 6:00 pm - 8:00 pm
 Colorado Access, Denver Highlands (Clock Tower) Building, 6th
floor, 10065 E. Harvard Ave., Denver, CO 80231
 May 22nd: Best Practices and Clinical Transformation
Group, 5:00 pm - 7:30 pm
 Colorado Access, Denver Highlands (Clock Tower) Building, 1st
floor, 10065 E. Harvard Ave., Denver, CO 80231
Meeting Resources on VC3
 Meeting Webpage
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http://vccc.co/index.php/2-27-2013-acc-bpct-meeting
Videos of tonight’s presentations
Downloadable presentations
Opportunity to blog about tonight’s topic
 Past Meetings
 November 28, 2012
 http://vccc.co/index.php/11-28-2012-acc-bpct-meeting
 August 29, 2012
 http://vccc.co/index.php/8-29-2012-acc-bpct-meeting
Best Practices and Clinical Transformation
Group Mission, Vision, and Values
Mission: To align with IHI’s Triple Aim of improving health
outcomes and patient experiences of care while
controlling the costs of care. RCCO 3 & 5 will focus
on 3 cost areas by:
 Reducing unnecessary ED utilization,
 Reducing unnecessary hospital readmission,
 Reducing unnecessary high cost imaging.
Vision:
Values:
For everyone to have the right care at the right time
from the right provider.
Clinical transformation is ‘patient-centric’; clinical
transformation is ‘provider-led’; clinical
transformation nets ‘value.’
Best Practices and Clinical Transformation
Group Goals & Strategies
 Endorse and support the “Tenets of Engagement.”
 Collect, analyze, interpret and act on individual and
collective data.
 Contribute to the Best Practices and Clinical Transformation
Group through demonstrations, presentations and adoption
of best practices.
 Communicate with RCCO partners, learn from PCMP
efforts, and educate and inspire colleagues through regular
use of the VC3, the web-based RCCO Virtual Community
for Collaborative Care.”
 Mobilize the ‘will for change’ through community
engagement
Best Practices and Clinical Transformation
Group Tenets of Engagement
 We are a Sharing and Learning community…with shared vision,
shared values and shared aims.
 We are leaders and we lead the improvement efforts.
 We are committed to change even if it is not comfortable.
 We move from ‘mine’ to ‘ours’ as our incentives become aligned.
 Our culture is based on relationships that are trusting, respectful,
open-minded, mutually supportive and non-competing.
 We believe that information that transforms care should not be
proprietary.
 We engage in healthy dialogue such that the status quo is
challenged and new ideas are respectfully and critically analyzed.
Best Practices and Clinical Transformation
Group Tenets of Engagement Continued
 Our focus is on the whole patient.
 The patients’ perspective is the most important perspective to
consider.
 Priority is given to relationships between providers and patients
and we help these thrive.
 We endeavor to expand and build collaborative relationships
between all stakeholders including but not limited to primary care,
specialty care, mental health, hospitals, long term care, payers.
 We embrace the concept of ‘team’, and include patients and
community members on the team.
 We will build a ‘think tank’ or ‘clearing house’ for best practices in
transforming care.
Integrating Behavioral Health
into Primary Care Practice
 Deb Parsons, MD
Medical Director, Region 3
Integrating Behavioral Health into Primary Care
Practice
 MH conditions result in
disproportionate bad
outcomes in physical health
 Acute and chronic medical
disease can initiate a MH
illness or exacerbate one
Colorado SDAC Enrolled – Moderate Chronic
January 2012– December 2012 Region 3
2500
N
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m
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r
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1500
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l
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500
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Condition Description
Colorado SDAC Enrolled – Moderate Chronic
January 2012– December 2012 Region 5
800
N
u
m
b
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r
o
f
C
l
a
i
m
s
700
600
500
400
300
200
100
0
Condition Description
Diagnostic Codes included in “Mental Health”
Condition
 Attention Deficit / Hyperactivity Disorder
 Bi - Polar Disorder
 Chronic Stress and Anxiety Diagnoses
 Conduct, Impulse Control, and Other Disruptive Behavior
Disorders
 Depression
 Depressive and Other Psychoses
 Eating Disorder
 Major Personality Disorders
 Schizophrenia
Diagnostic codes included in M1 conditions and masked
in the data
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Alcohol a/or Drug Services
Alcohol a/or Drug Training
Alcohol a/or Drug Screening
Alcohol a/or Drug Assessment
Alcohol a/or Drug Prevention
Alcohol a/or Drug Hotline
Alcohol a/or drug Halfway House, Per Diem
Alcohol/drug Abuse Svc Nos
Alcohol a/or Drug Intervention
Alcohol a/or Drug Outreach
Alcohol/drug Screening
Alcohol/drug Service 15 Min, 30 min, etc.
Alcohol/drugTx Program, Per hr; pr diem
Assay Of Amphetamines
Assay Of Barbiturates
Assay Of Benzodiazepines
Assay Of Breath Ethanol
Assay Of Cocaine
Assay Of Dihydrocodeinone
Assay Of Dihydromorphinone
Assay Of Ethanol
Assay Of Methadone
Assay Of Opiates
Assay For Phencyclidine
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Pt Education Noc Individ
Family/couple Counseling
Day Treatment For Individual
Treatment Plan Development
Pt Edu Re Alcohol Drinking Done
Pt Screened For Inj Drug Use
Pt Tlk Psych & Rx Opd Addiction
Pt Talk Psychsoc&rx Oh Dpnd
Ambulatory Setting Substance
Program Intake Assessment
Eval Self-Assess Depression
Child Sitting Services
Drug Confirmation
Drug Screen Qualitate/multi
Test For Chlorohydrocarbons
Chromotography Quant Sing
Quantitative Assay Drug
A ROADMAP : PEDIATRIC
PRIMARY CARE AND
BEHAVIORAL HEALTH
SERVICES INTEGRATION
Ly d i a M . P r a d o , P h D
Y v e t te B u x to n , M D
D aw n W i l s o n D av e n p o r t , P h D
R a c h e l L u n d , LC S W
The Mental Health
C e n te r o f D e nv e r
SERVICE INTEGRATION APPROACHES
 Consultation
 Co-Location
 Case Management Driven Models
 Integrated Service Models
Primary care has behavioral health specialists,
embedded in their practice, who can assess and work
with children and families, providing promotion,
prevention, early intervention and treatment services
in partnership with the primary care provider/s.
WHY INTEGRATE?
 “One of the best indicators of risk for emergence of
mental illness in the future is the presence of
parental or caretaker concern about a particular
child’s behavior. Primary care offices can screen for
risk by routinely inquiring about parental concern.
The prevention of mental illness and physical
disorders and the promotion of mental health and
physical health are inseparable.”
National Research Council and Institute of
Medicine (2009)
WHY INTEGRATE?
“Integrated primary care combines medical and
behavioral health services to more fully address the
spectrum of problems that patients bring to their
primary medical care providers. It allows patients to
feel that, for almost any problem, they have come to
the right place.”
Alexander Blount, Ed.D., Director, Center for
Integrated Primary Care
ASSESSING FEASIBILIT Y: INITIAL
DISCUSSIONS
 Primar y Care:
Client population/demographics
Staf fing patterns
Specific concerns/mental health needs
Payer sources
EMR provider
What are the primar y goals of primar y care/behavioral health
integration?
Who are the champions for ser vice integration?
How will this model be funded?
 Behavioral Health:
Ser vices available
Staf f allocations
How can behavioral health be most helpful?
ADDRESSING SYSTEMS AND PRACTICE
CHANGES
 Practice Management (screening, well visits,
scheduled consultations, unscheduled consultations,
therapy)
 Credentialing
 Scheduling/practice pace
 Consent to treatment/mandatory disclosure
 Modifications to the electronic medical record
 Documentation
 To bill or not to bill
 Outcomes measurement
 Sustainability
ADDRESSING THE DETAILS
 Role clarification
 Documentation/Coding/Confidentiality
 Billing (Who, what, when, how)
 Contracting
 Hiring
 Onboarding
 Reporting and supervisory relationships
 Ongoing communication, check -in meetings
 Outcomes: care outcomes, cost outcomes, data
capture; patient, provider, family perspectives?
FEEDBACK LOOPS
 How is it going for patients, providers, behavioral
health consultant, front desk staff?
 What’s working?
 What can be improved?
 Is the infrastructure supporting data, outcome and
billing requirements?
 Are we able to do what we set out to do?
THE BEHAVIORAL HEALTH CONSULTANT:
CORE COMPETENCIES
Clinical Practice
Practice Management Skills
Consultation Skills
Documentation Skills
Team Performance Skills
Administrative Skills
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RMYC/MHCD
Behavioral Health Integration:
Provider Perspectives
Rocky Mountain Youth Clinics:
Lori Cohn, Director of Social Services and Kim White, Pediatrician
Mental Health Center of Denver:
Yvette Buxton, Psychiatrist and Rachel Lund, Clinical Social Worker
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What is the impact
for the medical
providers?
“Health is a state of complete physical, mental,
and social well being, and not merely the
absence of disease or infirmity.”
World Health Organization, 1946
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Increased confidence to bring up issues
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Increased confidence discussing issues
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Strong belief that families will get the help they
need
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Increased understanding of how to identify BH
issues
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More time to address medical problems
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Greater ease for patients
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Reduced excuses not to engage
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Trust by association
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Truly feel that services are comprehensive
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Tremendous benefit of intervention in the moment
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Less “burdened"
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Provider collaboration/intervention
case studies
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C is an 11 year old boy
 Mom contacted the clinic after a friend of the family
committed suicide
 Mom expressed concern that C seemed very sad
 In clinic BH provider completed an assessment
 Determined he was likely experiencing normal grief
process
 Intervention included drawing pictures about his
feelings; he reported a positive effect
 Upon return to the clinic;
-sadness was improved
-expressed understanding about how future
events could also make him sad
-should that happen, he acknowledged the ability
to implement coping strategies
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R is a teen boy
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History of anxiety symptoms of ruminative thoughts/fears that impact functioning at home and school
Trouble falling asleep secondary to these worries & poor academics secondary to difficulty focusing
Several therapeutic sessions with BH provider focused on cognitive/behavioral techniques to address
anxiety symptoms
Patient and father very engaged in this therapy
Some improvement, but symptoms continued to significantly impact home and school functioning
Child psychiatrist asked to evaluate patient; generalized anxiety disorder diagnosed
By history, also concern of long-standing attention deficit disorder -diagnosed
Additionally, client diagnosed with tic disorder, present for several years, with moderately severe facial
tics.
Patient started on Tenex and work with BH provider continues
Combination of therapies resulted in greatly reduced anxiety, resolution of insomnia, improved focus
and school functioning, and minimal decrease in facial tics
To further address tic disorder-recommendation of neurology consult
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L and A are 7 and 8
year old sisters
 Both have some medical concerns and are acting
out at home
 Mom struggles with managing their behavior,
getting them to go to sleep and to wake up
Behavioral Health Intervention:
 discussed some strategies
 assessment of the situation revealed complex family
issues
 determined they needed services beyond what
could be managed in the clinic
 facilitated connection to MHC
 medical and BH providers consult regularly about
this families issues; as they continued to struggle
with academic and mental health follow through
 Primary care is greatest point of consistency and
support
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M is a 16 year old girl
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Presents in clinic with request for
pediatrician to take on prescribing of
psychiatric medications
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Recently discharged from the hospital on
antidepressant
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Ongoing treatment with outside MH
therapist, no current outpatient psychiatric
care.
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Medical provider asked child psychiatrist to
join appointment
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Patient revealed that she had increased
suicidal ideations and showed providers her
arms with dozens of cuts upon them
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Psychiatrist coordinated with outside
therapist and hospital for readmission
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D is a 7 year old boy
 Clinic visit centered around discussion of
behavior problems at school
 Difficulty sitting still, impulsive and behind in
school work
 Also active at home but doing better with
mom and grandma involved and concerned
 Discussed some strategies which they tried but
without significant improvement
 Complete assessments; including Vanderbilt(s)
 Positive for ADHD and ruled out other
concerns
 Discussed intervention strategies including
medication
 Consultation with medical provider resulting in
joint session with family
 Decision to try a small dose of meds.
 D has improved greatly BH and medical
providers continue joint meetings for follow up
and support
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“I have learned that success is to be measured not so much by the
position that one has reached in life as by the obstacles which he
has had to overcome while trying to succeed.”
~Booker T. Washington
Additional Perspectives
Adjourn
 Next ACC Program Best Practices and Clinical
Transformation Meeting
 May 22, 2013
 5:00 pm - 7:30 pm