Transcript Whole Person Care

Taking Care Of The Whole Person
Bradley P. Gilbert, MD, MPP
Chief Executive Officer, IEHP
Introduction
• Inland Empire Health Plan (IEHP) is a Joint Powers
Agency formed by Riverside and San Bernardino County
• IEHP has been serving Members since September 1996
• We currently serve over 1.13 million Members
• We are a not for profit entity with a public benefit
mission:
Mission Statement
To organize and improve the delivery of
quality, accessible and wellness based
healthcare service for our community.
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Nomenclature
• Whole Person Care
– Why would we do “partial” person care?
• Integrated Delivery Systems
– Is disintegrated better somehow?
• Population Health
– Are we not supposed to take care of the
population we serve?
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Potential Factors Impacting
Well being and Health Status
• Both important, not always linked
• Genetics – 30%
– Depends on condition
• Depression 40%
• Hypertension 30%
• Diabetes Type 2 – 8-14%
• Early / Mid Childhood Influences
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Parents… or not
Home environment
School
Trauma! Growing evidence of impact on well being
and health status
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Potential Factors... Cont.
• Social determinants – 15% contribution
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Socio-economic status – race, ethnicity, culture
Education
Income
Employment – work hazards, stress
Housing
Food
• Lifestyle Behaviors – 40% contribution
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Diet
Exercise
Smoking
Alcohol
Drugs
Risky other – Sex, hang gliding…
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Healthcare Access is not the
Primary Determinant of Health
Schroeder, NEJM 357; 1221-1228
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What can “We” Impact?
• Genetics – new targeted therapies
• Early / Mid Childhood Influences – Behavioral
Health
• Social Determinants
– SES – cannot change race or ethnicity, but can be
aware and address
– Education – community resources
– Employment – community resources, behavioral
health
– Housing – community resources
– Food – community resources
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What can “We” Impact? Cont.
• Lifestyle
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Information
Behavioral Health
Substance Use Treatment
Medications
Coaching
Support
• Access to Healthcare
– Coverage – ACA, SB75 (undocumented children)
– Availability – tough one, IEHP NEF
– Alternative Access – online MD, apps, tele-health, texting
• Ability to self manage
– See above!
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Then What Do We Do?
• Current delivery system fragmented
• Social Services / Community Resources
limited in some areas
• Physical health “separated” from Behavioral
Health and Substance Abuse Treatment
– Different providers
– Different payers
– Data sharing difficult
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Do Our Best To
Integrate and Coordinate
• Start with Physical and Behavioral Health
– Addresses many potential factors
– Clear data on impact of BH on health status –
early death, poor outcomes, increased utilization
and cost
– Seems like “low hanging fruit”
• Medi-Cal data demonstrates costs up to 40%
higher
– Cost for a given medical diagnosis if a behavioral
health diagnosis is present
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How?
• Multidisciplinary Care Teams co-located and
collaborating at point of care
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MD/NP/PA
Psychiatrist / Psychologist / LCSW / LMFT
RN / LCSW care management
Care coordinators / Navigators / Peer Coaches
Medical Assistants
• Assessments
– Health Risk Assessment – ADLs, health status,
conditions, etc.
– PHQ-9 (depression)
– GAD-7 (anxiety)
– Substance Use Assessment
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How?
• Stratification
– High Risk
• Care Plan
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Multi-disciplinary
Focused
Monitored
Evaluated on a regular basis
Daily huddles with team
• Care Coordination
– Across all domains
– Navigation
– Referrals to community resources with follow up
• Self Management
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Education
Coaching
Support
Referral
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Progress toward Fully Integrated care system:
6 levels of collaboration and coordination*
Coordinated care (off-site)
Level 1: Minimal collaboration
• Patients are referred to a provider at another practice site, and providers have
minimal communication.
Level 2: Basic collaboration
• Providers at separate sites periodically communicate about shared patients.
Co-located care (on-site)
Level 3: Basic collaboration on-site
• Providers share the same facility but maintain separate cultures and develop
separate treatment plans for patients.
Level 4: Close collaboration on-site
• Providers share records and some system integration.
Integrated care
Level 5: Close collaboration approaching an integrated practice
• Providers develop and implement collaborative treatment planning for shared
patients but not for other patients.
Level 6: Full collaboration in a merged integrated practice for all patients
Providers develop and implement collaborative treatment planning for all patients.
* Source: Heath B., Wise Romero P., Reynolds K. (2013). A Standard Framework for Levels of Integrated Healthcare. Washington,
D.C.: SAMHSA-HRSA Center for Integrated Health Solutions. http://www.integration.samhsa.gov/resource/ standard-framework-for14
levels-of-integrated-healthcare.)
Can It Be Done Really?
• Yes!
• IEHP - $20 million investment over two years
– Behavioral Health Integration Initiative
– Really… Complex Care Management
• 34 Sites
– Primary care clinics – county, FQHC’s
– Specialty Care Clinics
– Behavioral Health Clinics
– Community Based Adult Services (old ADHC)
– Assisted Living Sites
– Pain Medicine Clinics
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Can It Be Done Really? Cont.
• Jennifer Clancy Consulting
– Multi-disciplinary Team – psychiatrists, LLSWs, Clinic manager,
PCP (one double boarded)
– Program Development
– Coaching
– Data / Metrics Structure
• IEHP
– Internal infrastructure
– Data analysis
– dbMotion population health tool
• Sites
– Staffing paid for by IEHP
• NP, LCSW, Care Managers, Data Staff
– MOU’s – commitment to process and metrics
• UCSD
– Formal evaluation
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Outcomes
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Depression Scale
Anxiety Scale
Comprehensive Diabetes Care
Blood Pressure Control
BMI
Pain Scale
Member Satisfaction
Provider Satisfaction
ED Utilization
Inpatient Utilization
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Challenges
• Significant process and workflow changes needed for physician /
clinic offices
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Assessments
Care Plans
Accessing outside resources
Use of a team
Not just a medical/clinical issue!
• Thinking Population Health
– Cannot just be focused / pay attention to the patient and their chief
complaint that day
– Use of data
– Find the “non-users” of primary care
– Address preventative needs, other clinical issues at visits
• Coordination across disparate and non-communicating systems
– Use Health Plan resources
– On site Care Management
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Challenges cont.
• Data sharing issues
– Legal interpretation challenges
– Systems don’t talk to each other
• Resources limited
– Housing
– Other
• No organized ‘referral’ process
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Conclusion
• Why is there even a debate about Whole
Person Care or Integrating Care?
• Health Care delivery has the least overall
impact on health status
• Obviously critical for secondary and tertiary
care once an individual has chronic illness
• Mental health and substance use a significant
contribution to outcomes and cost of
individuals with chronic illness
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Key Changes In System
• Assessment! If you don’t know about it you
cannot address it
– Care Plans / Care Coordination
• Comprehensive approach – all factors
– May have to prioritize – eg. Integrating BH / SA
first
• Sharing of data!
– Privacy versus care
• Episodic Care vs Population Health
– Systematic approach to group
• Investment – IEHP!!
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