Transcript presentation ( format)

A Student-Centered Medical Home Model
for Integrated Student Health and
Counseling Services
ACHA, Friday, May 30, 2014, 1:45-2:45
Thomas J. Ferguson, M.D., Ph.D.
Dorje M. Jennette, Psy.D.*
Michelle Famula, M.D.
Cory N. Vu, O.D.
Sarah Hahn, Ph.D.
Sandy Santiago
*now at UC Santa Cruz
Objectives
Speaker: Tom Ferguson, MD, PhD, Medical Director, UC Davis SHCS
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Define Student/Patient -Centered Medical Home (PCMH)
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Describe models for provision of behavioral health
services in a PCMH model
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List examples of collaborative care
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Identify opportunities for suicide prevention
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Synergies: Access, engagement, & screening
Student-Centered Medical Home Model
Speaker: Cory Vu, O.D., Quality Improvement/Risk Manager, UC Davis SHCS
Patient-centered Medical Home (PCMH), is a team based
health care delivery model led by a PCP that provides
comprehensive and continuous medical care to patients
with the goal of obtaining maximized health outcomes.
The provision of medical homes may allow better access
to health care, increase satisfaction with care, and
improve health.
http://en.wikipedia.org/wiki/Medical_home
Student-Centered Medical Home Model
Speaker: Cory Vu, O.D., Quality Improvement/Risk Manager, UC Davis SHCS
http://parkwaymedicalgroup.com/patient-centered-medical-home/
Communication
Speaker: Cory Vu, O.D., Quality Improvement/Risk Manager, UC Davis SHCS
Student-Centered Medical Home Model
Speaker: Cory Vu, O.D., Quality Improvement/Risk Manager, UC Davis SHCS
Why PCMH in a Student Health Center?
Speaker: Cory Vu, O.D., Quality Improvement/Risk Manager, UC Davis SHCS
Healthy Campus 2020
Speaker: Cory Vu, O.D., Quality Improvement/Risk Manager, UC Davis SHCS
Healthy Campus 2020 Overarching Goals
 Create social and physical
environments that promote good
health for all.
 Support efforts to increase academic
success, productivity, student and
faculty/staff retention, and life-long
learning.
 Attain high-quality, longer lives free of
preventable disease, disability, injury,
and premature death.
 Achieve health equity, eliminate
disparities, and improve the health of
the entire campus community.
 Promote quality of life, healthy
development, and positive health
behaviors.
American College Health Association - Task Force on National Health Objectives
Context of Implementation
Speaker: Michelle Famula, M.D., Executive Director, UC Davis Health & Wellness
UC Davis SHCS
•Intermediate
stages of integration, the initial stages having involved an
organizational and electronic health record merge
•Mission
statement excerpt:
“…providing an integrated program of quality, accessible, cost sensitive
and confidential healthcare services, tailored to [students’] unique and
diverse needs…”
•Medical
Home certification in addition to general AAAHC accreditation
Student Health and Counseling Services
Speaker: Michelle Famula, M.D., Executive Director, UC Davis Health & Wellness
Accreditation: AAAHC, IACS & APA
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Counseling Services • Primary Care
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Individual/Group
Counseling
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Open Access
Appointments
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Drop-in Consultations
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Assigned PCPs
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Career Counseling
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Patient Centered
Medical Home
Specialty Care
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Psychiatry
Urgent Care
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Integrated Medical/
Mental Health
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Outreach and
Peer Programs
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Health Promotion
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Self Help Services
Student Health and Counseling Services
Speaker: Michelle Famula, M.D., Executive Director, UC Davis Health & Wellness
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70,740 SHCS Visits
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51,657 Medical Service Visits
(Primary, Specialty and Urgent Care)
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19,083 Mental Health Visits
(Psychology and Psychiatry)
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17,381 Unique Students Served
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15,850 Unique medical patients
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4,359 Unique mental health
clients
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17% received care from both
medical and mental health
Strategic Planning: Initiatives
Speaker: Sandy Santiago, Director of Clinic Support Services, UC Davis SHCS
Goal 1: Enhanced Organization Integration:
A single organization committed to working together to serve
students with every staff member aware of all available services,
freely accessing and sharing information for the holistic care of
students.
Objective 1: Develop a common framework for
administrative services
Objective 2: Create fully integrated clinical services
Objective 3: Integrated Outreach program across
Medical/Mental Health
Strategic Planning: Expected Outcomes
Speaker: Sandy Santiago, Director of Clinic Support Services, UC Davis SHCS
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Every UC Davis Student has a team of professionals to help
them (i.e., a “Medical Home”) and they understand how to
access services.
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Professionals support one another in this endeavor and there is
effective communication among providers in a uniform manner
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All are on the same computer network and electronic health
record (EHR)
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Traditions are maintained, built upon with joint training and
professional development to enhance communication
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There are clear administrative policies with respect to services
as well as human resources.
Practical Aspects of Implementation
Speaker: Sandy Santiago, Director of Clinic Support Services, UC Davis SHCS
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Executive Support
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Gathering input
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Staff Champions
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EDMT pilot – shared
record
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Clinical Staff Integration
Meetings
• Increase communication
• Build relationships
• Learn to understand each
other
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MOD/POD
Shared/Common Training
brief motivational interviewing
suicide risk assessment
Suicide Prevention
Speaker: Dorje Jennette, PsyD, CAPS Clinical Director, UC Santa Cruz Student Health
• Nationally, professional health care is
underutilized among those who are at risk of
completing suicide (e.g., Luoma, Martin, and Pearson, 2002)
• Integration has the potential to unlock
synergies that help students access and
adhere to the care they need
• Risk screening and safety planning—casting
a wider net
Suicide Prevention
Speaker: Dorje Jennette, PsyD, CAPS Clinical Director, UC Santa Cruz Student Health
• Students with gender identity stressors
associated with elevated suicide risk and low
health services engagement
• Bringing engagement to vulnerable
populations: Community Advising Network
• Psychotherapists embedded in partner
units such as the LGBTQIAQ center
• Establishing trust and bridging to
medical services
Multidisciplinary Teams
Speaker: Dorje Jennette, PsyD, CAPS Clinical Director, UC Santa Cruz Student Health
Quality Review: Continued discipline-specific peer review and
quality assurance teams, but formed integrated umbrella
Quality Committee
Treatment/Consult: Continued department-specific treatment
teams, but formed integrated:
1. Eating Disorder Management Team
2. Behavioral Health Consultation Team
3. ATOD Consultation Team
Collaborative Care
Speaker: Dorje Jennette, PsyD, CAPS Clinical Director, UC Santa Cruz Student Health
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Students with Eating Disorders
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Care team that regularly communicates/collaborates
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Unambiguous level-of-care recommendations
Students with ATOD concerns
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Care team that trained together in motivational interviewing
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Prescriber boundaries clear among providers and their patients
Transgender Students
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Unified designation of gender identity in EHR
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Streamlined transfer of documentation
ADHD
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Standardization and improved validity in diagnoses
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Reduced wait time for access to psychiatry
Richard Fee “Drowned in a Stream of Prescriptions” -NYT
Speaker: Dorje Jennette, PsyD, CAPS Clinical Director, UC Santa Cruz Student Health
Emerging Standards for ADHD Diagnosis
Speaker: Dorje Jennette, PsyD, CAPS Clinical Director, UC Santa Cruz Student Health
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ETS standards for accommodations
on SAT/GRE
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an evaluation within the last three
years
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by a specialized
psychologist/psychiatrist
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with first-hand childhood teacher
comments,
third-party evidence of current
impairment,
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a rule-out of alternative diagnoses,
and
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relevant testing (e.g., intellect, achievement,
processing speed, fluency, executive functioning,
language, attention, and memory)
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NCAA standards for athletes
testing + for stimulants
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Less specific than ETS, but
generally similar.
UCSB’s Elizabeth May, PhD, and
Edwin Feliciano, MD
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September 2012 UC-wide
conference call
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Emphasized the need for symptom
validity testing, which helps
distinguish between
malingering/inadequate effort and
true impairments/symptoms
ADHD Screening Process
Speaker: Dorje Jennette, PsyD, CAPS Clinical Director, UC Santa Cruz Student Health
PCP to continue Rx?
Off-campus
testing valid?
Student requesting
new ADHD diagnosis
ADHD
Screen
Psychiatry,
Psychotherapy,
Full Testing Battery,
PCP, and/or
Learning Resources
Outcome of Treatment
Speaker: Dorje Jennette, PsyD, CAPS Clinical Director, UC Santa Cruz Student Health
Retrospective chart review for subjective report of
improvement for patients treated medically
Started on
ADHD Treatment
Anxiety/Depression Treatment
Positive Response
30/32 = 94%
30/35 = 86%
Benefits of ADHD Screening
Speaker: Dorje Jennette, PsyD, CAPS Clinical Director, UC Santa Cruz Student Health
1. Improved accuracies in evaluation
2. Identification of true cause of symptoms/distress
3. Better academic outcomes (presuming treatment
improves attention which improves effective studying)
4. Reduced risk of abuse
5. Efficiencies; better allocation of resources
6. Establishing consistency/standards of practice
Integrated Urgent Care
Speaker: Tom Ferguson, MD, PhD, Medical Director, UC Davis SHCS
• Triage system Urgent Care (Shared Medical/CAPS)
• Resource Coordination
• Medical Officer of the Day (MOD) – Experienced
physician is available by pager for second opinion and to
assist Urgent Care as a resource for psychologists and PC
Providers
• Psychologist of the Day (POD) – Experienced
psychologist who is available by pager to assist PCP and
UC Triage Nurses in risk assessment and crisis response.
• ‘Warm Handoffs’ – POD can meet and greet patient in UC
or PC clinics to introduce and arrange appointment later in
day or week (or can assess urgently).
Integrated Urgent Care: Case Study
Speaker: Tom Ferguson, MD, PhD, Medical Director, UC Davis SHCS
CASE: UC patient assessed by RN for feeling anxious. Has
hypertension 148/110 and HR 90 with past medical history of
bipolar disorder and recently poor sleep. Past medical history of
psychosis and hospitalizations for bipolar disease.
• Triage RN identified acute medical and psychological assessment needs
• MOD requested POD to assess for patient safety concerns likely
exacerbation bipolar disorder and previous hospitalizations
• Psychologist assessed and diagnosed bipolar disorder needing higher level
of care. Patient agreed to voluntary psychiatric hospitalization for acute
care.
• Was normotensive at discharge from inpatient treatment without any
antihypertensive treatment but was taking medications for bipolar treatment.
Another Case Study
Speaker: Tom Ferguson, MD, PhD, Medical Director, UC Davis SHCS
CASE: 23 yo male seen by PCP for ankle injury
and as part of that visit is screened for depression
with PHQ 9. Score elevated at 21 with question 9
indicating daily thoughts of self harm.
•PCP does screening for suicide (ACP P4 screener) which scores low for
immediate risk and reviews concern with POD.
•POD facilitates assessment using warm handoff technique and initiates
therapy with messaging to PCP.
•Coordination of care and warm handoff improves likelihood of formal
psychological assessment and engagement in care.
•Collaborative approach in making treatment decisions (don’t all need
medications but do all need monitoring !).
Warm Handoffs Work Both Ways !
Speaker: Tom Ferguson, MD, PhD, Medical Director, UC Davis SHCS
CASE: 19 yo female international student assessed by CAPS
psychologist and determined to have recurrence of severe
depression. Had stopped fluoxetine when came to USA 6 months
ago. Not suicidal but difficulty getting out of bed and academic
problems. Next initial psychiatry appointment in 4 wks.
Psychologist pages MOD for consultation.
•MOD discusses case with the psychologist regarding best care for patient.
PCP appt 24 hours is decided – PCP copied on notes from MOD and
psychologist so is expecting the patient in clinic.
•Coordination cuts through ‘red tape’ and ‘bottlenecks’
•Does require PCP willingness to initiate and monitor therapy for
depression.
•PCP collaborate with psychiatrists via secure messaging for support.
Communication
Speaker: Tom Ferguson, MD, PhD, Medical Director, UC Davis SHCS
Lessons Learned
Speaker: Michelle Famula, M.D., Executive Director, UC Davis Health & Wellness
1. Importance of change management/rolling with resistance:
communication/processing/discussion
2. Strategic planning is critical to put leaders on the same page
3. Participating in CSI/workgroups/team meetings helps
sharing, communication, and understanding across
disciplines
4. Keep student-centered perspectives in mind (e.g.,
complex/high-risk students might be best served at times by
a one-stop integrated urgent care service)
What’s Next?
Speaker: Michelle Famula, M.D., Executive Director, UC Davis Health & Wellness
1. Open Access scheduling for psychological services
2. Alcohol screening/CCAPS tracking
3. ATOD team development; smoking cessation integration
4. More systematic referrals of patients from psychiatry to PCP
for stabilized med management (with consultation available),
conserving limited psychiatry resources.
Discussion/Questions/Contact Us
Thomas Ferguson, MD, PhD
Medical Director
[email protected]
Cory Vu, OD
Quality Improvement/Risk Manager
[email protected]
Dorje Jennette, PsyD
CAPS Clinical Director, UCSC
[email protected]
Sarah Hahn, PhD
CAPS Director
[email protected]
Michelle Famula, MD
Executive Director
[email protected]
Sandy Santiago
Director of Clinic Support Services
[email protected]