Transcript Clinical Issues in Outpatient Services: Re

Clinical Issues in Outpatient Services:
Re-tooling of Models
Bea Dixon
Examining new or different models of
providing outpatient services, including
review of best and/or promising practices
We are not unlike these would-be aviators of earlier times.
What components in our service delivery could give our
clients more “lift”?
What makes it possible for our clients to “fly”?
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Our Goal:
To offer service opportunities to persons with behavioral issues to pursue
optimal health, happiness, recovery, and a full and satisfying life in the
community via access to a range of effective services, supports, and
resources.
Our Task:
To transform a system that is essentially fragmented and reactive, to
one that is integrated and proactive, by:
1) Creating a collaborative continuum between PCP, mental
health and substance use providers;
2) Retooling our clinical approach and processes.
Task 1:
Creating a collaborative continuum between
PCP, mental health and substance use provider.
Person-Centered Healthcare Homes
Principles:
• Ongoing relationship with a PCP
• Care team who collectively
take responsibility for ongoing care
• Provides all healthcare or makes
appropriate referrals
• Care is coordinated and/or integrated
• Quality and safety are hallmark
• Enhanced access to care is available
• Payment appropriately recognizes the added value
From a client’s perspective
Access, coordination, practice efficiency:
“I receive exactly the care I
want and need,
exactly when and how I want
and need it.”
“I have one person I think of as my personal doctor.”
“The members of my care team work well together.”
“They coordinate the services I receive from other providers.”
“They are well organized, efficient, and do not waste my time.”
24/7 accountability:
“It is very easy for me to get care when I need it.”
A partnership approach with the care team:
“They ask for my ideas.”
“They give choices of treatment to think about.”
“They ask me about my goals in caring for my condition.”
“I am sure that they know my values, beliefs, and traditions.”
Patient Assessment of Chronic Illness Care www.improvingchroniccare.org
A system of care that organizes itself
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Quadrant II
BH PH 

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
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




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









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PCP (with standard screening tools
and guidelines)
Outstationed medical nurse
practitioner/physician at
behavioral health site
Nurse care manager at behavioral
health site
Behavioral health clinician/case
manager
External care manager
Specialty medical/surgical
Specialty behavioral health
Residential behavioral health
Crisis/ ED
Behavioral health and
medical/surgical inpatient
Other community supports
BH and Medical dimensions
Persons with serious mental illnesses could be served in all settings. Plan for and deliver
 choice and the specifics of the
services based upon the needs of the individual, personal
community and collaboration.
Quadrant I
BH PH 



Low
Behavioral health clinician/case
manager w/ responsibility for
coordination w/ PCP
PCP (with standard screening
tools and guidelines)
Outstationed medical nurse
practitioner/physician at
behavioral health site
Specialty behavioral health
Residential behavioral health
Crisis/ED
Behavioral health inpatient
Other community supports
Quadrant IV
BH PH 
Assignment of client
populations:
PCP (with standard screening
tools and behavioral health
practice guidelines)
PCP-based behavioral health
consultant/care manager
Psychiatric consultation
Quadrant III
BH PH 








PCP (with standard screening tools
and behavioral health practice
guidelines)
PCP-based behavioral health
consultant/care manager (or in
specific specialties)
Specialty medical/surgical
Psychiatric consultation
ED
Medical/surgical inpatient
Nursing home/home based care
Other community supports
Physical Health Risk/Complexity
Low
High
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Clinical Design for Adults with Low
to Moderate and Youth with Low to
High BH Risk and Complexity
CBHO
Food
Mart
Primary Care
Clinic with
Behavioral
Health
Clinicians
embedded,
providing
assessment,
PCP
consultation,
care
management
and direct
service
Partnership/
Linkage with
Specialty CBHO
for persons who
need their care
stepped up to
address
increased risk
and complexity
with ability to
step back to
Primary Care
Clinical Design for Adults with
Moderate to High BH Risk and
Complexity
Food
CBHO
Mart
Community Behavioral Healthcare
Organization with an embedded
Primary Care Medical Clinic with
ability to address the full range of
primary healthcare needs of
persons with moderate to high
behavioral health risk and
complexity
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Healthcare Homes for SMI Adults
Clinical Design for Adults with
Moderate to High BH Risk and
Complexity
Food
CBHO
Mart
Community Behavioral Healthcare
Organization with an embedded
Primary Care Medical Clinic with
ability to address the full range of
primary healthcare needs of
persons with moderate to high
behavioral health risk and
complexity
Question: Can a typical
Primary Care Clinic serve as
a successful holding
environment for adults with
Serious Mental Illness?
Primary Care Services
embedded in a CBHO is an
important strategy for
addressing the health
disparities for the SMI
population.
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Task 2:
Retooling our clinical approach and skills.
Good outcomes (clinical, satisfaction, cost, and function) result from productive
interactions. To have productive interactions the system needs to develop four areas at
the level of the practice:
a. Delivery system design:
Who is on the health care team and
how do we coordinate our clients’ care?
Chronic Care Model
b. Clinical decision support:
What is the best care and
how do we make it happen every time?
c. Self-care management:
How do we help clients live with their conditions?
d. Clinical information systems:
How do we capture & use critical information
to improve clinical care?
E. Wagner, Group Health
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IMPACT program – Doubling the effectiveness of usual care for
depression. How was this achieved?
One home with stepped care option
Application of elements of the Chronic Care Model:
Collaboration and coordination:
A care team consisting of a PCP and
Behavioral Health Specialist/Care
Coordinator, in consultation with psychiatrist when
needed.
Person-Centered Home
Delivery system
Decision-support
Self-management
Clinical information system
 Clinical guidelines and evidence-based practices are embedded in daily
practice:
Use of screening tools, flow sheets as reminders, and
standardized intervention modules
 Self-management training opportunities,
Education, joint decision making
 A robust online client tracking system/registries to ensure better clinical outcomes, reduce
medical costs and waste.
Example of a service approach
Behavioral health services in primary care settings
Proposed Flow:
The patient's primary care physician works with a
care coordinator to develop and implement a
treatment plan (medications and/or brief,
evidence-based therapy).
Person-centered
Delivery design system
Clinical decision support
Self-management
Clinical information system
Care coordinator and primary care providers consult with a
designated prescriber when needed.
Cont’d
Care Coordinator (nurse, social worker or psychologist):
• Educates the patient about mental health conditions;
• Supports psychiatric medication therapy prescribed by the
patient's primary care provider if appropriate;
• Coaches patients using Behavioral Activation, Motivational
Interviewing ,or other relevant counseling techniques;
• Offers a brief (six-eight session) course of evidence-based
counseling, such as Problem-Solving treatment (PST) or Cognitive
Behavioral Therapy;
• Monitors symptoms for treatment response;
• Completes a relapse prevention plan with each patient who has
improved;
Cont’d
Psychiatrist consults with the care coordinator and primary care physician on the care of patients who do not
respond to treatments as expected.
The Care coordinator measures symptoms at the start of a patient's treatment and
regularly thereafter using brief, structured screening and clinical rating scales that
are appropriate for the specific disorders that are being treated. (PHQ-9 (for depression), GAD-7 (for
anxiety disorders), GAIN-SS (GAIN SDScr) (for chemical dependency)
Stepped care:
Treatment is adjusted based on clinical outcomes and according to evidence
based treatment algorithms and principles
Aim for a 50 percent reduction in symptoms within 10-12 weeks
If client is not significantly improved at 10-12 weeks after the start of a
treatment plan, change the plan (increase of medication dosage, a change to a
different medication, addition or change of psychotherapy, a combination of
medication and psychotherapy, or other treatments suggested by the team
psychiatrist).
The IT system contains rating scales/screening tools that enable care coordinators to track and monitor clinical
improvement.
Washington State GA-U Project Clinical Flow
Person Centered Healthcare Home Clinical Design based on IMPACT Model
- Systematic outcomes tracking (e.g., PHQ-9 for depression, GAD-7 for anxiety)
- Treatment adjustment as needed including stepped care (e.g. up to specialty BH)
(based on clinical outcomes, evidence-based algorithm; in consultation with team psychiatrist)
- Relapse prevention
New Patient’s first
Visit to PCP includes
behavioral health
screening
YES
Possible
BH Issues?
Behavioral Health
Assessment by BH
Professional working
in primary care
Need BH
Svcs?
YES
Clients with Low to Moderate BH need enrolled
in Level 1; to be case managed and served in
primary care by PCP and BH Care Coordinator
with support from Consulting Psychiatrist and
other clinic-based Mental Health Providers
Clients with Hi Moderate to High need referred
to Level 2 specialty care; PCP continues to
provide medical services and BH Care
Coordinator maintains linkage; this is a timelimited referral with expectation that care will be
stepped back to primary care
Referrals to other needed services and supports (e.g. CSO, Vocational Rehabilitation)
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Physical health monitoring of SMI clients:
1. Assure regular screening and tracking at the time
of psychiatric visits for all behavioral
health consumers receiving psychotropic
medications—check glucose and
lipid levels, blood pressure, weight ,and Body Mass
Index (BMI).
2. Record and track changes and response to
treatment and use the information to
obtain and adjust treatment accordingly.
Example of a service approach
Services in CBHOs (for moderate to severe client populations)
Care Team and care coordination
Evidence-based treatment – with decision support:
Cognitive Behavior Therapy
(depression, anxiety)
Motivational Interviewing
Dialectic Behavioral Therapy
Trauma therapy
Person-centered
Delivery design system
Clinical decision support
Self-management
Clinical information system
Outcome-based: Validated assessment tools: pre- and post
Self-management support
Referral, with coordination of care, to primary care, level I S/U outpatient services
(including ambulatory detoxification), medication assisted treatment.
Clinical Information System (registry system)
Stepped Care
Example of a service approach
Services in CBHOs (for severe to serious client populations)
Care Team and care coordination
Evidence-based treatment – with decision support:
Cognitive Behavior Therapy for psychosis
Motivational Interviewing
Co-occurring disorder treatment
PACT
Recovery coaching
Family psycho-education
Supported education
Supported employment
Supported housing
Trauma therapy
Person-centered
Delivery design system
Clinical decision support
Self-management
Clinical information system
Outcome-based: Validated assessment tools: pre- and post
Cont’d
Self-management support:
Illness self-management (an evidence based program)
Peer Support
Peer-run programs, i.e. Clubhouse
Referral, with coordination of care, to primary care, level I S/U outpatient services
(including ambulatory detoxification), medication assisted treatment.
Clinical Information System (registry system)
Stepped Care
Physical health monitoring:
1. Assure regular screening and tracking at the time
of psychiatric visits for all behavioral
health consumers receiving psychotropic
medications—check glucose and
lipid levels, blood pressure, weight ,and Body Mass
Index (BMI).
2. Record and track changes and response to
treatment and use the information to
obtain and adjust treatment accordingly.
3. Medical nurse practitioners/ primary care
physicians located in behavioral health.
4. A primary care supervising physician.
5. An embedded nurse care manager.
6. Identify the current primary care provider for
each individual and assure coordination.
7. Provide education.
8. Wellness programs.
Possible challenges experienced by clinical staff
Forming a care team versus working in silos
Coordinating care
Incorporating evidence-based practices, creating and using standardized work modules:
•
•
•
•
•
We’ve always done it this way. Why change?
It will replace my clinical judgment.
I don’t have time for it.
It will lead to “cookbook practice.”
It’s too difficult.
Basing treatment on clinical outcomes and according to evidence based treatment
algorithms and principles.
Cont’d
Possible challenges (cont’d)
Moving into a role of shared expertise with the client
At least 50% of clients leave the office without
understanding what they were told.
Participatory decision making occurs in about 25%
of office visits.
Creating an IT system that contains rating scales/screening tools and
enables care coordinators to track and monitor clinical improvement.
Summary
Primary Care/Behavioral Healthcare Integration presents exciting opportunities:
Transforming a system that is essentially fragmented and reactive, to one that is
integrated and proactive, by:
1)
Establishing a collaborative continuum between PCP, mental health and substance
use providers:
Person-Centered Healthcare Home
2)
Retooling our clinical skills and processes:
IMPACT
Chronic Care Model
Various applications in PCP and BHCO practices
Questions or Comments?