2009 06 09 introduction to integrated care
DESCRIPTION
About Marillac Clinic - Grand Junction, Colorado Clinic Eligibility • 200% of federal poverty level • Mesa County residents • Medical program serves uninsured ages 18-64 • Dental program serves uninsured, CHP+, and Medicaid.TRANSCRIPT
Steve Hurd, Ph.D.
970.244.2235
Where Two Great Rivers Meet:
Evolution of Integrated Care
MarillacClinic
Bridging the healthcare gap
AboutMarillacClinic
Clinic Eligibility• 200% of federal poverty level
• Mesa County residents
• Medical program serves uninsured ages 18-64
• Dental program serves uninsured, CHP+, and Medicaid. No age limitation.
Major Depression
Anxiety
Panic Disorder
Alcohol
Binge Eating
Any Diagnosis
0% 15% 30% 45% 60%
Prevalence ComparisonsMarillac Clinic vs. PHQ 3000
AboutMarillacClinic
IntegratedCare
Guiding Philosophy:
Meeting several patient needs in one visit results in greater
efficiency for both patient and provider. Integrated
Care
IntegratedCare
1. Minimalcollaboration
2. Collaboration at a distance
3. Basic on-siteCollaboration
4. Close Collaboration in a partly integrated system
5. Close Collaboration in a fully integrated system
McDaniel, Hepworth, and Doherty (1992)
IntegratedCare
$
$
$$
$$
$$
• Financial investment at start-up.
• Incentives to participate in collaborative care services:
• Single fee for entire office visit• Reduced group fees
• “Carving-in” diverse funding sources removes barriers to care.
IntegratedCare
•1 Medical Director—Physician
• 3 Physician Assistants
• 2 Nurse Practitioners
• 3+ FTE counselor positions• Family Therapist• 2 Licensed Social Workers• Case Manager• Psychiatric Nurse
• Psychiatrist - 8 Hours Weekly
OurStaff
Location Location Location
LessonsLearned
Having mental heath and medical providers in adjacent
offices is essential.
Location Location Location
LessonsLearned
LessonsLearned
PsychologistFamily Therapist
& PsychiatristAddictionsCounselor
CaseManager
MedicalExam
Rooms
MedicalExam
RoomsMedicalProviderStations
MedicalExam
Rooms
MedicalExam
Rooms
MedicalExam
RoomsMedical
AssistantStations
MedicalExam
Rooms
MedicalExam
Rooms
MedicalExam
Rooms
Reception Front Office
The Bathroom
Rule
Bathroom
Enhanced Record Keeping
LessonsLearned
All providers work from the same medical record
Enhanced Record Keeping
LessonsLearned
Crucial for Integrated Care:• Face-sheet• Mental health flowsheet• Health history questionnaire
Case M
anagement
LessonsLearned
Assists providers to stay on schedule
Essential for helping patients access
community resources
Case M
anagement
LessonsLearned
Shared Success Fosters Trust
LessonsLearned
Improved patient outcome becomes the single most
important source of encouragement for functioning
as a single team.
Shared Success Fosters Trust
LessonsLearned
Collegiality rather than Hierarchy
Collegiality rather than Hierarchy
LessonsLearned
Medical and mental health providers have equal status
within the team.
Collegiality rather than Hierarchy
LessonsLearned
Community Collaboration: Inter-agency referral agreements
MarillacClinic
Colorado West Mental
Health
Violence & AddictionsAgencies
CommunityMedicalClinics
LocalHospitalLessons
Learned
0%
7.5%
15.0%
22.5%
30.0%
Year 1 Year 2 Year 3 Year 4 Year 4.5
9.00%6.00%
8.00% 8.00%4.00%
Hospitalization E.R. Visit
Outcomes
Usage of St. Mary’s Services by Marillac’s Integrated Care Patients
0%
7.5%
15.0%
22.5%
30.0%
Year 1 Year 2 Year 3 Year 4 Year 4.5
9.00%6.00%
8.00% 8.00%4.00%
Hospitalization E.R. Visit
Outcomes
Usage of St. Mary’s Services by Marillac’s Integrated Care Patients
0%
7.5%
15.0%
22.5%
30.0%
Year 1 Year 2 Year 3 Year 4 Year 4.5
9.00%6.00%
8.00% 8.00%4.00%
Hospitalization E.R. Visit
Outcomes
During year 4, only 17% of hospital admissions were for mental health or substance
abuse conditions
Usage of St. Mary’s Services by Marillac’s Integrated Care Patients
Change in Hospitalization Rate (per 1,000) for All Marillac Integrated Care Patients
Jan-April 2003Jan-April 2004
Psychiatry Length of Stay January - April 2003 versus 2004
Psychiatry Charges: Jan – Apr 2003 versus Jan – Apr 2004
Stepped Care
Step 1
Screening, diagnostic, and preventative services; parental education
Stepped Care
Stepped Care
Step 2
Active treatment in primary care, involvement of care-giver and allied health professional to prevent relapse
Stepped Care
Stepped Care
Step 3
Psychiatric consultation at the primary-care setting when emotional or behavioral problems persists or
complications occur
Stepped Care
Stepped Care
Step 4
Referral to specialty setting for highly complex presentations or poor outcomes occur at Step 3
Stepped Care
Step 4
Referral to specialty setting for highly complex presentations or poor outcomes occur at Step 3
Stepped Care
More complex presentations may
begin at Step 3 or 4
Marillac Papers to date• Mauksch, L., Reitz, R. Tucker, S., Hurd, S., Russo, J., and Katon, W. Improving quality of
care for mental illness in an uninsured, low-income primary care population. General Hospital Psychiatry, 2007, 29, (4), 302-309.
• Mauksch, LB. Katon, W., Russo, J., Tucker, S., Walker, E Cameron, J. The content of a low income, uninsured primary care population: Including the patient perspective. Journal of the American Board of Family Practice, 2003, (16) 278-289.
• Cameron, J. and Mauksch, L. Collaborative Family Health Care in an Uninsured Primary Care Population: Stages of integration. Families, Systems and Health, 2002, 20(4) 343-363.
• Mauksch, L. B., Tucker, S. M., Katon, W. J., Russo, J., Cameron, J., Walker, E., & Spitzer, R. Mental illness, functional impairment, and patient preferences for collaborative care in an uninsured, primary care population. Journal of American Board of Family Practice 2001, 50(1), 41-47.
MarillacClinic
Bridging the healthcare gap