Transcript DF – Branson Missouri 20150603 1

A Roadmap to Integrated Care:
Triumphs and Trials of a Long-Tenured
Integrated Delivery System
Branson, Missouri
June 3, 2015
© 2015 Cherokee Health Systems
All Rights Reserved
© 2015 Cherokee Health Systems
All Rights Reserved
© 2015 Cherokee Health Systems
All Rights Reserved
© 2015 Cherokee Health Systems
All Rights Reserved
Our Mission…
To improve the quality of life
for our patients through the blending of
primary care and behavioral health.
Together…Enhancing Life
© 2015 Cherokee Health Systems
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Overview of Cherokee Health Systems
Blending Behavioral Health into the PatientCentered Medical Home
Transforming the Delivery of Behavioral Healthcare
Enhancing the Patient Centered Medical Home
© 2015 Cherokee Health Systems
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Cherokee Health Systems
Last year: 64,300 patients
New Patients: 16, 672
488,209 Services
Number of Employees: 620
Provider Staff:
Psychologists - 51
Primary Care Physicians - 24
NP/PA (Primary Care) - 39
Cardiologist - 1
Nephrologist - 1
Pharmacists - 11
Comm. Health Coord. - 37
Psychiatrists - 10
NP (Psych) - 10
LCSWs - 69
Dentists - 2
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Primary Service Area
Ke n t u c k y
V i rg i n i a
CLAIBORNE
CAMPBELL
UNION
GRAINGER
HAMBLEN
ANDERSON
KNOX
JEFFERSON
COCKE
Te n n e s s e e
SEVIER
LOUDON
MCMINN
BLOUNT
MONROE
HAMILTON
G e o rg i a
Cherokee Health
Systems
Together…Enhancing Life
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North
C a ro l i n a
Knoxville/Knox
County, TN
Population: 655,400
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Cherokee Health Systems
Washburn, TN 37888
Population – 645
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Cherokee Health Systems
Penetration into the General and Medicaid Populations
• 3 year (FY2012-2014) penetration into the general population
Unduplicated patients
Total area population
Penetration
96,964
1,019,386
9.5%
• 3 year (FY2012-2014) TennCare (Medicaid) penetration
Unduplicated Medicaid patients
Total Medicaid enrollment
Penetration
41,027
178,212
23.0%
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Strategic Emphases
Blending Behavioral Health and Primary Care
Outreach to Underserved Populations
Training of Health Care Professionals
Population-Based Care
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Strategic Emphases
Telehealth Applications
School-Based Health Services
Safety Net Preservation
Value-Based Contracting
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MENTAL HEALTH CENTER OF
MORRISTOWN
Original
CHS Office
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BANK OF COMMERCE – MORRISTOWN,
TENNESSEE
1960
Cherokee Health Systems
Forks in the Road/Epochs of Development
• Rooted in the mission of community mental health
• Circuit riding outreach into primary care
• Primary care operations
• Embedded Behavioral Health Consultant role
• Blending the cultures, becoming an FQHC
• Behaviorally enhanced Healthcare Home
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Cherokee Health Systems:
Merging the Missions of
CMHCs and FQHCs
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Community Mental Health Centers: What were they?
What are they? What happened?
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Historical roots – Action for Mental Health (1961), Community
Mental Health Center Act (1963), 1960’s social activism
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Community Mental Health Centers -- the initial model
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Federal block grants gave the States authority over the program
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Psychosocial rehabilitation and “priority populations”
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Managed care and behavioral health carve-outs
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Advocacy/consumer groups, peer support and recovery models
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Federal, State and Medicaid cutbacks
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Community Health Centers: What were they?
What are they? What happened?
• Historical roots – “War on Poverty”, Economic Opportunity Act
(1964), 1960’s social activism
• Neighborhood Health Centers -- the initial model
• Avoided Federal block granting, Federal authority maintained
• Stability of mission throughout history
• Service expansion grants for mental health services
• Central to Federal health policy
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Blending Behavioral Health into
the Patient Centered Medical Home
Cherokee Health Systems’ Clinical Model
© 2015 Cherokee Health Systems
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Blending Behavioral Health into Primary Care
Cherokee Health Systems’ Clinical Model
Behaviorists on the Primary Team
The Behavioral Health Consultant (BHC) is an embedded, full-time
member of the primary care team. Psychiatric consultation at the
point of care.
Service Description
The BHC provides brief, targeted, real-time
assessments/interventions.
Typical Service Scenario
When clinically indicated, PCP “hands off” patient to BHC.
Collaboration on a plan of care follows.
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Role of Behavioral Health Consultant (BHC)
Scope of Practice
• Available “on-demand”
• Management of psychosocial aspects of chronic
and acute diseases
• Application of behavior change to address
lifestyle and health risk issues
• Consultation and co-management of mental
health and psychosocial issues
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© 2015 Cherokee Health Systems
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© 2015 Cherokee Health Systems
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Considerations for PCP Referral for
Behavioral Health Concerns
• Diagnostic clarification and intervention planning
• Facilitate consultation with psychiatry regarding psychotropic
medications
• Behavior and mood management
• Suicidal/homicidal risk assessment
• Substance abuse assessment and intervention
• Panic/Anxiety management
• Interim check of psychotropic medication response
• Co-management of somaticizing patients
• Parenting skills
• Stress and anger management
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© 2015 Cherokee Health Systems
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Considerations for PCP Referral for
Behavioral Medicine Concerns
HEALTH BEHAVIOR/DISEASE MANAGEMENT
• Medication Adherence
• Weight Management
• Chronic Pain Management
• Smoking Cessation
• Insomnia/Sleep Hygiene
• Psychosocial & Behavioral Aspects of Chronic Disease
• Any Health Behavior Change
• Management of High Primary Care Utilization
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An Afternoon in the Life of a BHC
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12 yo male with abdominal pain (new)96150
40 yo male with chronic depression, DM, HTN (f/u) 90832
58 yo female with fibromyalgia, insomnia (new) 96150
44 yo female with chronic pain, suicide attempt (f/u) 90832
58 yo male with post-MI, hx SA and meth lab (f/u) 90832
59 yo female with HTN, DM, CAD, Depression (new) 90791
56 yo male with Panic, Obesity (f/u) 90832
52 yo female with grief (new) 90791
13 yo male with obesity, weight management (f/u) 96152
9 PATIENTS IN 4 HOURS
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The Behavioral Health Consultant in Primary Care
Characteristics, Skills and Orientation to Practice
Characteristics
• Flexible, high energy level
• Team Player
• Interest in health and fitness
Skills
• Finely honed clinical assessment skills
• Behavioral medicine knowledge base
• Cognitive behavioral intervention skills
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The Behavioral Health Consultant in Primary Care
Characteristics, Skills and Orientation to Practice
Orientation to Practice
• Action-oriented, directive, focus on patient
functioning
• Emphasis on prevention and building resiliency
• Utilizes clinical protocols and pathways
• Invested in educating patients, health literacy
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The Integrated Care Psychiatrist
• Access and Population-Based Care
• Enhance the Skills of Primary Care Colleagues
• Treatment Team Meetings
• Telepsychiatry
• Stabilize Patients and Return to Primary Care
• Co-Management of Care
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The 5 Core Components
Medical
Appointment with
PCP
PCP & BHC Discussion
BH Consultation
PCP & BHC Discussion
BHC and/or PCP
Consults Psychiatry
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The Patient Centered Medical Home
A PCMH puts patients at the
center of the health care system, and provides
primary care that is “accessible, continuous,
comprehensive, family-centered, coordinated,
compassionate, and culturally effective.”
(American Academy of Pediatrics)
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PCMH “Joint Principles”
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Personal physician
Physician led practice team
Whole person orientation
Care is coordinated and integrated
Quality and safety are hallmarks
Enhanced access to care
Payment reform
Adopted by AAFP, AAP, ACP, AOA Feb., 2007
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NCQA
• National Committee on Quality Assurance (NCQA)
– 501(c)(3) dedicated to improving health care quality
– NCQA offers “recognition” programs for various aspects of
clinical care: diabetes, cardiovascular disease, back pain
– One of the recognition programs is for PCMH
– 3 levels of accreditation: Level 1 (lowest), Level 2, and Level
3 (highest)
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PCMH 2014
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Re-engineering Primary Care:
An Integrated Team Based Model
• Functions of care delivery shared across team
• Access to BH expertise “where behavioral
problems shows up”
• Improved communication
• Improved care coordination
• Expanded health management support
• Supported patient engagement
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© 2015 Cherokee Health Systems
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Fostering the Informed and Activated Patient
• Assess readiness to change.
• Mutually establish behavioral goals and behavior change
strategies.
• Employ motivational interviewing and problem focused
interventions.
• Support patient self-management and self-regulation skills.
• Foster resiliency and personal responsibility for health.
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Cherokee’s Patient-Centered Medical Home Model
• Embedded Behavioral Health Consultant on the PC Team
• Real time behavioral and psychiatric consultation available to PCP
• Focused behavioral intervention in primary care
• Behavioral medicine scope of practice
• Encourage patient responsibility for healthful living
• A behaviorally enhanced Healthcare Home
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A Roadmap to Integrated Care:
Triumphs and Trials of a Long-Tenured
Integrated Delivery System
Branson, Missouri
June 3, 2015
© 2015 Cherokee Health Systems
All Rights Reserved
CFO Job Qualifications
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Healthcare Experience: none
Insurance Experience: none
Management Experience: none
Age: Mid-20’s
Eager to Learn
Willing to Work Hard
Desire to Succeed
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Firstly, I’d like you to put aside your preconceived
notions of what constitutes “funny”…
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© 2015 Cherokee Health Systems
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© 2015 Cherokee Health Systems
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Growing Up at Cherokee…
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1960 – Incorporated
1978 – Dennis Freeman Hired as CEO
1984 – Blaine Health Center
1987 – Union-Grainger Primary Care
1992 – Managed Care Growth
1994 – TennCare Began
1995 – CHS vs. Magellan
2006 – Relocation & Growth
© 2015 Cherokee Health Systems
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Cherokee Health Systems
Revenue History
P4P
$60,000,000
Economy
Down
$50,000,000
$40,000,000
CHS vs.
Magellan
TennCare
Begins
$30,000,000
FQHC
Management
$20,000,000
1st
Primary Care
$10,000,000
$1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 2015
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The
Groundbreaking
Guide for the
Rest of Us!
Mission, Model,
Manpower, Money
Investing in Technology
Financing the Model
for Sustainability
Everything you ever
wanted to know about
behavioral health
integration but were
afraid to ask!
Find the
REAL WORLD
answers
you’ve been
looking for!
Dennis S. Freeman, PhD
Parinda Khatri, PhD
Foreword by Bob Franko,
world-renowned IC Blogger
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Where does
the CFO Fit?
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Management Structure
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Infrastructure
• Financial Systems
• Technology
• Facilities
• Revenue Cycle
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Financial Systems
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General Ledger / Accounting Structure
Payroll / Personnel
Purchasing & Logistics
Banking
Debt
Investments
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Reporting Challenges of Integration
Behavioral
Medical
Developmental
Dental
Pharmacy
Radiology
Laboratory
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Integration?
Medical
Dental
Developmental
Behavioral
Laboratory
Pharmacy
Radiology
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Integration!
Medical
Dental
Developmental
Behavioral
Laboratory
Pharmacy
Radiology
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Reporting Challenges
• Integrated Organization
• Segregated Business Units
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Technology Systems
• Records Management & Documentation (not IT)
– Paper
– Electronic
• Communications
– Phones, Faxing & Communications
– WAN, Internet, Video
• Maintenance & Support
– Hardware & Software
• Reporting Capabilities
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(16)
© 2015 Cherokee Health Systems
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Facilities
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Construction & Renovation
Maintenance
Cleaning
Security & Safety
– Video
– Access Control
– Alarms
• Parking
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5th Street – 6 Weeks Before Integration
Group
Room
Office
Office
Office
Office
Office
Office
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Integration (Phase 1)
Office
Office
Office
Office
Office
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Integration (Phase 2)
Office
Office
Office
Office
Office
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Integration (Phase 3)
Office
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Phase 4
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Phase 5
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Proposed
Project Site
Walter P. Taylor Homes
Aerial View – 2015
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© 2015 Cherokee Health Systems
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Revenue Cycle
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Contracting
Credentialing
Practice Management System
Registration & Verification
Coding & Charge Entry
Billing & Follow-Up
Collections
Chart Audits
Feedback & Training
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© 2015 Cherokee Health Systems
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© 2015 Cherokee Health Systems
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4 Disciplines of Execution
• Focus on the Wildly Important
• Act on Lead Measures
• Keep a Compelling Scoreboard
• Create a Cadence of Accountability
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Cherokee’s WIGs
Improving Access
Enhancing
the Clinical Model
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How will WE help Cherokee
accomplish the Wildly
Important
?
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 Accounting
 Credentialing
To support the organization with
effective performance of financial
services and communication of
financial information
To verify that our providers are qualified
and privileged to serve our patients and
generate revenue
 Facilities
To ensure that corporate properties
strengthen our work and enhance the
patient experience
 Purchasing
To arrange for our staff to have the
resources they need in the most costeffective and timely manner
 Revenue Cycle
To maximize revenue on our services in
an ethical, and caring manner
© 2015 Cherokee Health Systems
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What do I want to accomplish this year?
• Grow a Culture of Excellence
– Set the standard
– Adequate is not adequate
– Errors are not acceptable
• Empower Positive Leaders
– Trust/Integrity
– Listening
– Ownership
• Enhance Corporate Performance
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A CFO’s Guide to Survival (and Success)
in Integrated Care
• Service Mentality
– Money is a TOOL, not the MISSION
• Strive for Improvement in Everything
– If it ain’t broke, BREAK IT.
• Listen and Observe
– Proximity to patients trumps back-office mandates
• Follow the Golden Rule
– Matthew 7:12
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Questions
?
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