cj peek, phd
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NC Center of Excellence for Integrated Care: Advocates for Practice Change Regina Dickens, Ed.D ., LCSW Maria Dover, MS, LMFT. What is our history?. CJ Peek, PhD. - PowerPoint PPT PresentationTRANSCRIPT
© 2010 NC Center of Excellence for Integrated Care icarenc.org1
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NC Center of Excellence for Integrated Care: Advocates for
Practice Change
Regina Dickens, Ed.D., LCSWMaria Dover, MS, LMFT
© 2010 NC Center of Excellence for Integrated Care icarenc.org2
CJ Peek, PhD
What is our history?
© 2010 NC Center of Excellence for Integrated Care icarenc.org3
The North Carolina Center of Excellence for Integrated Care builds on the work of a Foundation-sponsored program, The ICARE Partnership, which
pioneered the integration of care in primary care practices between 2006 and 2010 through a broad
inter-agency, multi-disciplinary partnership.
© 2010 NC Center of Excellence for Integrated Care icarenc.org4
Rene Descarte (1641)Philosopher & mathematician
Commonly given credit for establishing separate domains for the physical and mental-- and the philosophical basis for the "mind-body split".
CJ Peek, PhD
© 2010 NC Center of Excellence for Integrated Care icarenc.org5
“Integrated Care” is an effort to better match or blend clinical services to the realities that patients and their
clinicians face daily.”
Medical Care Behavioral Health Care
A legacy of separate and parallel systems
A forced choice between:• Two kinds of problems• Two kinds of clinicians• Two kinds of clinics• Two kinds of treatments• Two kinds of insurance
CJ Peek, PhD
© 2010 NC Center of Excellence for Integrated Care icarenc.org6
Why the system doesn’t work…
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Common clinical presentations don’t stay neatly in those medical or BH boxesBehavioral / psychosocial is part of medical care
• 70% of all PC visits have psychosocial drivers• 50% of all BH care is done by PCP’s• 67% of all psychoactive drugs prescribed by PCP’s• Referral to BH/CD hard to navigate; often doesn’t
connectCJ Peek, PhD
© 2010 NC Center of Excellence for Integrated Care icarenc.org8
Untreated Depression = More Healthcare Use• Depressed patients use 3 times more
healthcare services
• Depressed patients have 7 times more emergency visits
• Depression is associated with longer hospital stays
© 2010 NC Center of Excellence for Integrated Care icarenc.org9
Trauma associated with Intoxicant Use:
• In 2005, up to 60% of US trauma center patients tested positive for one or more intoxicants
• Of these 1 in 4 had a second drug and alcohol related injury in the same year.
Maier, 2009
© 2010 NC Center of Excellence for Integrated Care icarenc.org10
NC primary care providers (PCPs) and behavioral health providers agree that:• There is difficulty finding a referral for publicly or
uninsured patients
• There are few opportunities to develop relationships with primary care providers
• There is a huge benefit to community psychiatrists being available for consultation and establishing a working relationship with the PCPs.
© 2010 NC Center of Excellence for Integrated Care icarenc.org11
One Solution is Integrated Primary Care
Integrated primary care is a service that combines medical and behavioral health services to more fully address the spectrum of problems that patients bring to their primary medical care providers. It allows patients to feel that, for almost any problem, they have come to the right place.
Alexander Blount
A definition…
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A look at integrated care…
© 2010 NC Center of Excellence for Integrated Care icarenc.org13
Patient Centered Care includes:INTERNAL COLLABORATION
OPERATIONAL
CLINICAL
FINANCIAL
- quality care- patient driven
- systems- organization- process improvement
- coding- billing- reimbursement
© 2010 NC Center of Excellence for Integrated Care icarenc.org14
Patients
Medical Records
Nurses and medical assistants
Receptionists
Psychiatrists
Behavioral Health Therapists
Physician
ON-SITE Integrated Care Team
All supported by common chart, documentation standards, billing procedures,
and clinic management system
NP’s PA’s
© 2010 NC Center of Excellence for Integrated Care icarenc.org15
Integrated Care ProgramNurse screens clients at establish care and
annual appointments
Physician sees clientand validates screening
Physician introducesclient and therapist
Physician and therapistprovide team approach
for coordinated care
▪Screening▪Assessment▪Brief supportive
counseling▪Therapy▪Case management▪Medication monitoring▪Coordinated team care
Behavioral Health Services integrated with Primary Health Care:
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Integrated Care WorksRandomized Control Trials demonstrate:• More effective medication treatment• Reduced depression severity• Improved general health status• Decreased disability• Better occupational function• Improved patient satisfaction• Cost-effectiveness
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Our Current Projects
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CHIPRA: A Quality Demonstration Grant
The CHIPRA statute mandates the
‘experimentation’ and ‘evaluation’ of several
promising ideas related to improving the quality of children’s healthcare.
Slide by Stacy Warren
© 2010 NC Center of Excellence for Integrated Care icarenc.org19
Needs of America’s Children American children
experience worse health and higher levels of mortality than do children from most other developed nations and receive recommended care only 42% of the time
UNICEF, The State of World’s Children, 2009 (visited April 10,2009
Mangione-Smith R, Decristofaro A, Setodji C, Keesey Jl, Adams The Quality of Care Received by Children and Adolescents in the US. Pediatric Academy Societies, E-PAS2006:59:4500.1
Slide by Stacy Warren
© 2010 NC Center of Excellence for Integrated Care icarenc.org20
Medicaid Enrollees on the RiseIn 2009, 60 million people were on Medicaid and over
half of them were under 18.
1 in every 4 American children are on MedicaidApproximately 31% of NC children are on Medicaid
www.statehealthfacts.org 2008-2009
Slide by Stacy Warren
© 2010 NC Center of Excellence for Integrated Care icarenc.org21
Center for Medicare and Medicaid Services (CMS) is committed to demonstrating improvement in Medicaid/CHIP systems through:
• The synthesis of data and activities from diverse Medicaid/CHIP systems
• Providing Technical Assistance to States • Tracking improvement using metrics• This includes addressing health care disparities, long term health
care needs supports and services and builds on the synergy and coordination of efforts with public health agencies, education and mental health care systems to improve the health care outcomes for children.
Slide by Stacy Warren
© 2010 NC Center of Excellence for Integrated Care icarenc.org22
CHIPRA Categories:
• A - Experiment with and evaluate the use of new and existing measures of quality for children
• B – promote the use of health information technology (HIT) for the delivery of care for children
• C – evaluate provider-based models to improve the delivery of care
• D – demonstrate the impact of model pediatric EHRs (electronic health records)
• E – creating targeted models to demonstrate their impact on health, quality and cost.
© 2010 NC Center of Excellence for Integrated Care icarenc.org23
Category A Core Measures
• NC will use its Community Care infrastructure to implement and evaluate the use of the new set of 24 quality measures identified by AHRQ and CMS.
• NC will expand upon the current data collection system to incorporate the core set of children’s health measures and will work with local practices on the implementation, feedback and the meaningful use of the quality information for improvements in performance.
© 2010 NC Center of Excellence for Integrated Care icarenc.org24
CHIPRA Category A Measures Update• Categories for the 24 Core Measures
– Prenatal, Immunizations, Screening, Well Child Visits, Dental, Availability, Upper respiratory, ED, Inpatient Safety, Asthma, ADHD, Mental Health, Diabetes, Family Experience
• Unique to North Carolina– EPSDT Report Card, Dental Varnishing, MCHAT, Adolescent
and School Age Screening, Obesity, Foster Care Kids Linked to a Medical Home
• Reporting Timeline– Reporting a subset of the measures annually to CMS as of
12/2011 and quarterly to practices starting 6/2011
© 2010 NC Center of Excellence for Integrated Care icarenc.org25
24 Core MeasuresThree stages of progress….
We’re currently reporting on 8 of the 24 core measures requested by CMS through the IC.
We’re attempting to report on an additional 8 of the 24 core measures using paid claims.
Working with DMA, SCHS and Vital Records to capture the remaining eight measures.
Potential roadblocks…• The identification of current sources for PICU/NICU data
• CAHPS is only reported once every three years
• Transition from old to new systems makes data collection problematic..immunizations and birth certificate data
• It’s difficult to identify CHIP recipients in the claims system
© 2010 NC Center of Excellence for Integrated Care icarenc.org26
New Measures• EPSDT Report Card
– Lead, vision, well visits, developmental screening, autism
• Dental Varnishing – Pediatric preventive measure from IC
• 99420 Reports X 3 – MCHAT, School Age Screen, Adolescent Screen
• Obesity– Follow up for clients with an obesity diagnosis
• Foster Care– Kids Linked to a Medical Home
© 2010 NC Center of Excellence for Integrated Care icarenc.org27
Quality Improvement• Quality Improvement will focus on…
Measure Description
#7 Weight assessment for children/adolescents
#8 Screening for social/emotional development
#10 - #12 Well Child Visits for 15 months, 3-6 years and 12 – 21 years
#18 ED Utilization
Unique to North Carolina: Dental fluoride varnish, Follow-up for obesity, MCHAT, School Age and Adolescent Screening
© 2010 NC Center of Excellence for Integrated Care icarenc.org28
Reporting• Reporting to CMS through CHIP Annual
Reporting Template (CARTS) system• Reporting to practices through Provider Portal
© 2010 NC Center of Excellence for Integrated Care icarenc.org29
Category C--CHIPRA ‘Connect’
NC will strengthen the medical home for children and youth with special health care needs (CYSHCN) by testing and
evaluating provider-led, community-based models that will identify, treat and coordinate the care of CYSHCN,
particularly children with developmental, behavioral and /or mental health disorders
Slide by Stacy Warren
© 2010 NC Center of Excellence for Integrated Care icarenc.org30
CHIPRA Connect Demonstrate a provider-based model of
care for CYSHCN by testing and evaluating provider-led, community-based models
Practices will utilize the AAP Mental Health Toolkit
Emphasis on linkages and reliable communication systems
© 2010 NC Center of Excellence for Integrated Care icarenc.org31
CHIPRA CONNECT PROJECT
Learning Collaborative for Cohort I begins
PCMH Certification
Medical Home
2015
2014
2013
2012
2011
Learning Collaborative for Cohort II beginsObesity
Oral Health
PCP Pre-Work
Mental Health Toolkit
Mental Health Toolkit
Obesity
Oral Health
Risk Stratification Tool
© 2010 NC Center of Excellence for Integrated Care icarenc.org32
Cohort 1 ParticipantsCommunity Care of the Sandhills• Dr. Masoud Ahdieh• ABC Pediatrics• Sandhills Pediatrics• Harnett County Health Department
AccessCare
• Goldsboro Pediatrics
Community Care Plan of Eastern Carolina• Washington Pediatrics• Surf Pediatrics
Northwest Community Care Network• Surry County Health and Nutrition Center • Kids Count Pediatrics • Westgate Pediatrics • Robinhood Pediatrics
© 2010 NC Center of Excellence for Integrated Care icarenc.org33
Each strategy will propel quality improvement both independently and in concert with the other strategies
AQuality
Measures
CMedical Home
Measures enable ongoing, flexible tracking of Medical Home Impact
Medical Homes provide data on feasibility, cost and value of measures
EHR supports Medical Home
implement quality care
EHR enables will enable
efficiencies and timely tracking
and meaningful use of quality
measures
Measures inform and evaluate
impact of EHR
Medical Homes will d
rive
service-oriented, quality EHR
developmentD
PediatricElectronic
HealthRecord
Slide by Stacy Warren
© 2010 NC Center of Excellence for Integrated Care icarenc.org34
Category D-Pediatric Electronic Health Record• Existing EHR systems often do not optimally support the provision of
health care to children. • The goal of Category D is to develop a model EHR Format for
children, demonstrate that it can be readily used, and package it in a way that facilitates broad incorporation into EHR systems.
• NC, through its Community Care program, will work closely with the NC Regional Extension Center (REC) in the implementation of the model Electronic Health Record for Children (EHR).
• PEHR consultants in all 14 Networks will work with providers/medical homes interested in implementing the model PEHR.
© 2010 NC Center of Excellence for Integrated Care icarenc.org35
How do we implement practice change?
© 2010 NC Center of Excellence for Integrated Care icarenc.org36
Steps to Practice Change• Identify and Convene stakeholder groups to:
– Design/update needs assessments for each targeted practice group
– Identify current and emerging evidenced based best practice models
– Set quality assurance/ model fidelity measures for targeted practice areas
– Monitor the process– Identify ways to improve family involvement in
healthcare
© 2010 NC Center of Excellence for Integrated Care icarenc.org37
Steps for Practice Change (continued)• Establish learning collaboratives• Establish a cadre of experts to deliver training and
TA• Establish Evaluation Protocols with outside Evaluator
to monitor Center of Excellence goals and outcomes• Establish procedures to monitor lessons learned and
adjust for needed changes on a quarterly basis
© 2010 NC Center of Excellence for Integrated Care icarenc.org38
How Can Families Be More Involved?
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The Medical Home Family Index• Purpose: to better understand how families of children and
youth with special healthcare needs view the services they receive from their PCP.
• As a practice moves to become a ‘Medical Home’ it is important to capture how the family perceives those efforts and where there is room for improvement.
• Ex. of question: I am asked by our PCP how my child’s condition affects our family (impact on siblings, the time my child’s care takes, lost sleep, extra expenses, etc).
• Survey is provided in both English and Spanish.
© 2010 NC Center of Excellence for Integrated Care icarenc.org40
CHIPRA TEAM• Dr. Marian Earls, Physician Champion• Stacy Warren, Project Director [email protected]; (919) 715-1088• Janie Shivar, Category A Clinical Coordinator [email protected]; (919) 863-0063• Marla Satterfield, CHIPRA Connect Pediatric Program Manager [email protected]; (919) 863-0063• Maria Dover, CHIPRA Connect Clinical Coordinator [email protected]; (919) 863-0063• Kern Eason, Category D Pediatric EHR Consultant [email protected]; (919) 745-2426
© 2010 NC Center of Excellence for Integrated Care icarenc.org41