Transcript Integrated Care at TPC - PCMH - Patient

Integrated Care at
The Providence Center
2014
Presented by:
Nelly Burdette, PsyD
Director of Integrated Care
The Providence Center
Background
Rhode Island’s largest community
mental health organization with an
annual budget of $42 million.
In 2013, we served 12,777 people with
services provided statewide through 14
service locations in Providence,
Burrillville, Cranston, Pawtucket, and
Warwick, and 13 client residences in
Providence.
5 main service divisions
TPC’s main administrative offices and adult
outpatient services on North Main Street in
Providence.
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Adult (SPMI and Health Home)
Child and Family
Wellness, Employment and
Education
Residential Services
Crisis Care
TPC Demographics
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Gender
 54% Male
 46% Female
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Age
 0-3: 1%
 4-8: 5%
 9-12: 5%
 13-18: 12%
 19-34: 21%
 35-50: 29%
 51-64: 22%
 65+: 5%
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Race and Ethnicity
 White: 43%
 Latino: 21%
 Other/Unknown: 18%
 Black: 13%
 Native American: 3%
 Asian: 2%
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Primary Reimbursement
 Medicaid UBH: 19%
 Medicaid NHP: 17%
 Medicare: 14%
 Medicaid: 16%
 BCBS: 5%
 Uninsured: 4%
 Private: 2%
TPC Primary Diagnoses
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Most common across
TPC (n=7501)
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Depression:26%
Adjustment D/o: 11%
Schizophrenia: 10%
Mood Disorder: 9%
ADHD: 8%
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Most common across
Health Home (n=1878)
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Schizophrenia 33%
Depression: 27%
Bipolar: 13%
Mood Disorder: 12%
Adjustment D/o: 7%
CY2013 - CSP Health Home
Target Conditions
ChronicBackPain
GERD
CVA
7%
Fibromyalga
5%
SleepApnea
0%
2%
ThyroidDisease
3%
Hyperlipidemia
3%
1%
Arthritis
Diabetes
10%
8%
LeadPoison
TraumaticBrainInjur
SeizureDisorder
y 2%0%
1% Asthma
10%
ObesityOverWeight
12%
Hypertension
17%
Hypercholesterolemi
a
12%
HeartDisease
2%
Hepatitis
5%
CMHC and FQHC
Collaboration
Models
Behavioral Health
embedded
in medical
Psychologist
within FQHC
Health Home Team
within
FQHC
Primary care
embedded in
behavioral health
Medical nurse care
managers within
CMHC
(SAMHSA
PBHCI Grant)
FQHC embedded
within CMHC
Goals of models
Behavioral Health within
Primary Care Setting
Increase awareness of behavioral
health care issues for both
provider and patient
Increase access to
behavioral health
screening and intervention
Improve chronic disease
management
Behavioral health within PC
Part-time psychologist
at largest PCHC site
 Specially trained in
integrated care within a
primary care setting
 Referrals comprised of a
combination of traditional
mental health and chronic
disease lifestyle
management
Model based on 30-minute
triage/CBT interventions
averaging 3-6 visits per
patient, mostly triage and
referral
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Behavioral health within PC
Providence Community Health Centers at
Prairie Avenue Collaboration
Outpatient child and adult
practice embedded within
PCHC with bilingual
therapist and bilingual
child/adult psychiatrist
New Health Home
currently piloting
Diagnostic Rankings
Top three behavioral health
diagnoses within FQHC (PCHC @ Prairie)
Male & Female > 18 y/o
1. Depressive Disorder
NOS
2. Recurrent Depression
3. Anxiety Disorder NOS
Top three physical health diagnoses
within embedded medical center of
CMHC (PCHC @ NM)
Male & Female > 18 y/o
1. Diabetes, Type 2
2. Hyperlipidemia
3. Hypertension
Goals of models
Primary Care within
Mental Health Setting
Improve morbidity and mortality of consumers with
mental illness and addictions
Decrease barriers to access to physical health care for
consumers with behavioral health issues
Improve health literacy for both providers and
clients
Primary care in behavioral health
Providence
Community Health
Centers at North
Main Street
Opened June 2011
Physician, nurse, medical
assistant & health center
director
TPC-employed integrated care
manager with a health literacy
focus
“We are partners in health.”
“We treat complex patients
who have complex problems,
many of whom have not sought
health care for a long time. I
talk with my patients about
about understanding what they
have to do to get healthy and
how I can support them.”
-Dr. Tariq Malik, M.D., M.P.H., primary care physician at
Providence Community Health Centers at North Main
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Personal trainers who are also
trained case managers
Individualized fitness and
healthy lifestyle assessment
performed by the health mentor
for every participant
Fitness plan, including eating,
exercise, and health promotion
Weekly individual meetings with
a health mentor to participate
in fitness activities from walking
to gym attendance
• Assistance with access to
fitness resources
•Opportunities for group exercise and healthy eating education
Primary care in behavioral health
SAMHSA funded PBHCI Grant
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Awarded in 2010, 4 year grant
Emphasis placed on embedding
medical nurse care managers in Home
Health SPMI Teams
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Education
and triage related to
management of chronic disease, greater
access to primary care
PHQ9,
AUDIT, Stanford Self-Efficacy,
Self-Rated Abilities for Health Practices
and SF-36 administered
Baseline,
then every 3 months until
one year completion, physical health
measures including, BMI, Weight Loss,
Blood Pressure, HbA1c, HDL, LDL and
Triglycerides
PBHCI Results
Hospitalization Utilization
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Psych hospitalization and psych ER use significantly decreased
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Medical hospitalizations and medical ER visits increased.
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All types of hospitalizations showed a net decrease (156 days less
net)
Psych Hosp (n=132):
428 days to 256 days
Med Hosp (n=132):
105 days to 146 days
SU Hosp (n=133):
49 days to 24 days
Psych ER (n=134):
72 times to 33 times
Med ER (n=134):
135 times to 196 times
SU ER (n=130):
14 times to 3 times
Cost Savings (n=350)
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Psych Hospitalization
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428 days to 256 days =
$122,120 savings
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National average $710 per day2
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Psych ER
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72 times to 33 times =
$27,300 savings
National average $700 per day1
SU Hospitalization
49 days to 24 days =
$24,250 savings
National average $970 per day2
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TOTAL
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$173,670 savings for 350
individuals designated as
SPMI
PBHCI Results
Self-Efficacy (Stanford)
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Clients belief that they can communicate with physicians,
manage disease in general, manage symptoms of disease,
increase nutritional abilities, improve psychological well-being
has significantly improved over one year with nurse care
coordination.
Communicate with physicians
From 7.67 to 7.98 (p=.050)
Manage disease in general
From 6.51 to 6.76 (p=.052)
Manage symptoms
From 5.61 to 5.92 (p=.033)
Nutrition abilities
From 17.87 to 18.97 (p=.012)
Psychological Well-being
From 14.65 to 16.10 (p=.003)
Total self-efficacy
From 62.74 to 65.39 (p=.038)
Health practices
From 19.93 to 21.22 (p<.001)
PBHCI Results
Physical Health Measures
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Statistically significant improvements over the course of one
year in the below lab values
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Drawbacks: lab data difficult to obtain and as a result n quite small
HgbA1c (n=35 to 13 to 14):
9.4 to 8.7 to 7.6 (p=.032)
TC (n=78 to 26 to 23):
231 to 205 to 199 (p<.001)
LDL (n=58 to 18 to 18):
154 to 123 to 128 (p<.001)
Triglycerides (n=56 to 21 to 26):
300 to 306 to 248 (p=.017)
BP Systolic (n=56 to 41 to 47):
126.55 to 123.32 to 124.3 (p<.001)
BP Diastolic (n=56 to 41 to 47):
80.5 to 78 to 79.4 (p<.001)
Waist Circumference in cm (249 to 163
to 193):
116 to 114 to 113 (p<.001)
PBHCI Results
Subjective Health (SF-36)
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Every aspect of health perceived to have statistically significantly
improved over the course of the year, except bodily pain and health
perception.
General MH
54.77 to 61.82 (p<.001)
Physical Functioning
58.57 to 66.69 (p<.001)
Role Limitations (MH)
44.1 to 57.8 (p<.001)
Role Limitations (PH)
51.32 to 60.19 (p=.027)
Social Functioning
61.11 to 70.04 (p<.001)
Vitality
42.8 to 48.62 (p=.001)
PBHCI Results
If alcohol screening (AUDIT) initially at-risk (>8) AT
BASELINE, there was a statistically significant decrease in
risk after one year of nurse care management participation
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Mean scores from 15.35 to 9.43 to 9.65. This is a significant decrease at
p<.001. (n=40 to 23 to 20)
If depression screening (PHQ-9) initially in the moderate
range (>10) AT BASELINE (n=158), there was a statistically
significant reduction over the course of one year.
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Mean: 16.15 to 12.17 to 10.72 (p<.001)
PBHCI Results: BMI
Weight change descriptives for BMI>30 at baseline:
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6 Months
12 Months
Lost weight
78 (49%)
101 (54%)
No change
19 (12%)
22 (12%)
Gained weight
62 (39%)
64 (34%)
Lost 5% weight
33 (21%)
48 (26%)
Lost <5%/Gained <5%
109 (69%)
108 (58%)
Gained 5% weight
17 (11%)
31 (17%)
BMI (200 to 152 to 186): 38.5 to 37.1 to 36.9 (p=.003)
Health Literacy: Before the
Medical Visit
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Integrated care coordinator meets with SPMI (Health Home)
patient a few minutes prior to physician entering the room to:
 assist pt in focusing on the top 3 issues he/she would like
addressed today
 review logistics of PC: prepare pt about length of appt, any longer
than anticipated wait times, etc.
 review pt’s mood, new stressors and any emotional issues that
could be impacting physical health
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At the same time, physician reviews an interagency form:
 includes pt’s mental health diagnoses, psychiatric medications
and any relevant notes from mental health team
Health Literacy: During the
Medical Visit
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Integrated care coordinator stays with pt for
the length of exam to:
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be a witness to the points of difficulty between pt
and physician
provide support to the physician should the pt
experience difficulty communicating
provide support to the pt should pt experience
difficulty understanding medical concepts or
recommendations
Health Literacy: After the
medical visit
Bottom Line
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Integrated care must be infused into the core
mission, values and commitment of an
organization to be successful.
There is no right way to integrate, but there
are known strategies that are evidence-based
Addressing the integrated care needs of the
SPMI population is a challenge, but is no
longer optional.
Citations
1. Stranges, E. (Thomson Reuters), Levit, K. (Thomson Reuters),
Stocks, C. (Agency for Healthcare Research and Quality) and
Santora, P. (Substance Abuse and Mental Health Services
Administration). State Variation in Inpatient Hospitalizations for
Mental Health and Substance Abuse Conditions, 2002 2008.
HCUP Statistical Brief #117. June 2011. Agency for Healthcare
Research and Quality, Rockville, MD. http://www.hcupus.ahrq.gov/reports/statbriefs/sb117.pdf
2. Russo, C. A. (Thomson Healthcare), Hambrick, M. M. (AHRQ),
and Owens, P. L. (AHRQ). Hospital Stays Related to
Depression, 2005. HCUP Statistical Brief #40. November 2007.
Agency for Healthcare Research and Quality, Rockville, MD.
http://www.hcup-us.ahrq.gov/reports/statbriefs/sb40.pdf
Contact Information
Nelly Burdette, PsyD
Director of Integrated Care
The Providence Center
530 North Main St
Providence, RI 02904
Direct Office: 401/415-8820
Email: [email protected]