clinical issues in outpatient services: re-tooling of models bea dixon examining new or different...
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Clinical Issues in Outpatient Services: Re-tooling of Models
Bea DixonExamining new or different models of
providing outpatient services, including review of best and/or promising practices
We are not unlike these would-be aviators of earlier times.
What components in our service delivery could give our clients more “lift”?
What makes it possible for our clients to “fly”?
2
Clinical Design for Adults with Low to Moderate and Youth with Low to
High BH Risk and Complexity
Primary Care Clinic with Behavioral
Health Clinicians
embedded, providing
assessment, PCP
consultation, care
management and direct
service
Partnership/Linkage with
Specialty CBHO for persons who need their care stepped up to
address increased risk and complexity with ability to step back to Primary Care
Clinical Design for Adults with Moderate to High BH Risk and
Complexity
Community Behavioral Healthcare Organization with an embedded
Primary Care Medical Clinic with ability to address the full range of
primary healthcare needs of persons with moderate to high
behavioral health risk and complexity
Food Mart
CBHOFood MartCBHO
Clinical Design for Adults with Low to Moderate and Youth with Low to
High BH Risk and Complexity
Primary Care Clinic with Behavioral
Health Clinicians
embedded, providing
assessment, PCP
consultation, care
management and direct
service
Partnership/Linkage with
Specialty CBHO for persons who need their care stepped up to
address increased risk and complexity with ability to step back to Primary Care
Clinical Design for Adults with Moderate to High BH Risk and
Complexity
Community Behavioral Healthcare Organization with an embedded
Primary Care Medical Clinic with ability to address the full range of
primary healthcare needs of persons with moderate to high
behavioral health risk and complexity
Food Mart
CBHOFood MartCBHO
PCP
Medical Home:
Primary Care/Behavioral Healthcare Integration: exciting opportunities!
Person-centered healthcare home:
PCP & Behavioral
Health Specialist
Clinical Design for Adults with Low to Moderate and Youth with Low to
High BH Risk and Complexity
Primary Care Clinic with Behavioral
Health Clinicians
embedded, providing
assessment, PCP
consultation, care
management and direct
service
Partnership/Linkage with
Specialty CBHO for persons who need their care stepped up to
address increased risk and complexity with ability to step back to Primary Care
Clinical Design for Adults with Moderate to High BH Risk and
Complexity
Community Behavioral Healthcare Organization with an embedded
Primary Care Medical Clinic with ability to address the full range of
primary healthcare needs of persons with moderate to high
behavioral health risk and complexity
Food Mart
CBHOFood MartCBHO
Close collaboration and coordination between person-centered home
and CBHO
With steppedcare option
Our Task:
To transform a system that is essentially fragmented and reactive, to one that is integrated and proactive, by:
Our Goal:
To offer service opportunities to persons with behavioral issues to pursue optimal health, happiness, recovery, and a full and satisfying life in the community via access to a range of effective services, supports, and resources.
1) Creating a collaborative continuum between PCP, mental health and substance use providers;
2) Retooling our clinical approach and processes.
Task 1:
Creating a collaborative continuum between PCP, mental health and substance use provider.
Person-Centered Healthcare Homes
Principles:
• Ongoing relationship with a PCP• Care team who collectively
take responsibility for ongoing care• Provides all healthcare or makes
appropriate referrals• Care is coordinated and/or integrated • Quality and safety are hallmark• Enhanced access to care is available• Payment appropriately recognizes the added value
From a client’s perspective “I receive exactly the care I want and need,
exactly when and how I want and need it.”Access, coordination, practice efficiency:
“I have one person I think of as my personal doctor.” “The members of my care team work well together.”“They coordinate the services I receive from other providers.”“They are well organized, efficient, and do not waste my time.”
24/7 accountability:
“It is very easy for me to get care when I need it.”
A partnership approach with the care team:
“They ask for my ideas.”“They give choices of treatment to think about.”“They ask me about my goals in caring for my condition.”“I am sure that they know my values, beliefs, and traditions.”
Patient Assessment of Chronic Illness Care www.improvingchroniccare.org
Quadrant II Quadrant IV
Quadrant I Quadrant III
Clinical Design for Adults with Low to Moderate and Youth with Low to
High BH Risk and Complexity
Primary Care Clinic with Behavioral
Health Clinicians
embedded, providing
assessment, PCP
consultation, care
management and direct
service
Partnership/Linkage with
Specialty CBHO for persons who need their care stepped up to
address increased risk and complexity with ability to step back to Primary Care
Clinical Design for Adults with Moderate to High BH Risk and
Complexity
Community Behavioral Healthcare Organization with an embedded
Primary Care Medical Clinic with ability to address the full range of
primary healthcare needs of persons with moderate to high
behavioral health risk and complexity
Food Mart
CBHOFood MartCBHO
Clinical Design for Adults with Low to Moderate and Youth with Low to
High BH Risk and Complexity
Primary Care Clinic with Behavioral
Health Clinicians
embedded, providing
assessment, PCP
consultation, care
management and direct
service
Partnership/Linkage with
Specialty CBHO for persons who need their care stepped up to
address increased risk and complexity with ability to step back to Primary Care
Clinical Design for Adults with Moderate to High BH Risk and
Complexity
Community Behavioral Healthcare Organization with an embedded
Primary Care Medical Clinic with ability to address the full range of
primary healthcare needs of persons with moderate to high
behavioral health risk and complexity
Food Mart
CBHOFood MartCBHO
Clinical Design for Adults with Low to Moderate and Youth with Low to
High BH Risk and Complexity
Primary Care Clinic with Behavioral
Health Clinicians
embedded, providing
assessment, PCP
consultation, care
management and direct
service
Partnership/Linkage with
Specialty CBHO for persons who need their care stepped up to
address increased risk and complexity with ability to step back to Primary Care
Clinical Design for Adults with Moderate to High BH Risk and
Complexity
Community Behavioral Healthcare Organization with an embedded
Primary Care Medical Clinic with ability to address the full range of
primary healthcare needs of persons with moderate to high
behavioral health risk and complexity
Food Mart
CBHOFood MartCBHO
Medical complexity
Behavioral complexity(MH/SU)
Clinical Design for Adults with Low to Moderate and Youth with Low to
High BH Risk and Complexity
Primary Care Clinic with Behavioral
Health Clinicians
embedded, providing
assessment, PCP
consultation, care
management and direct
service
Partnership/Linkage with
Specialty CBHO for persons who need their care stepped up to
address increased risk and complexity with ability to step back to Primary Care
Clinical Design for Adults with Moderate to High BH Risk and
Complexity
Community Behavioral Healthcare Organization with an embedded
Primary Care Medical Clinic with ability to address the full range of
primary healthcare needs of persons with moderate to high
behavioral health risk and complexity
Food Mart
CBHOFood MartCBHO
A system of care that organizes itself
WhoWhat
Where When How
Helping Consumers Find the Right Healthcare Home
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Integration Policy Initiative
Low: V-codes, mild depression,mild anxiety, sleep disorder, somaticdisorder, SU disorder
Clinical Design for Adults with Low to Moderate and Youth with Low to
High BH Risk and Complexity
Primary Care Clinic with Behavioral
Health Clinicians
embedded, providing
assessment, PCP
consultation, care
management and direct
service
Partnership/Linkage with
Specialty CBHO for persons who need their care stepped up to
address increased risk and complexity with ability to step back to Primary Care
Clinical Design for Adults with Moderate to High BH Risk and
Complexity
Community Behavioral Healthcare Organization with an embedded
Primary Care Medical Clinic with ability to address the full range of
primary healthcare needs of persons with moderate to high
behavioral health risk and complexity
Food Mart
CBHOFood MartCBHO
Moderate: Moderate depression, moderate anxiety (including PTSD), sleep disorder, somatic disorder, SU disorder (abuse)
Clinical Design for Adults with Low to Moderate and Youth with Low to
High BH Risk and Complexity
Primary Care Clinic with Behavioral
Health Clinicians
embedded, providing
assessment, PCP
consultation, care
management and direct
service
Partnership/Linkage with
Specialty CBHO for persons who need their care stepped up to
address increased risk and complexity with ability to step back to Primary Care
Clinical Design for Adults with Moderate to High BH Risk and
Complexity
Community Behavioral Healthcare Organization with an embedded
Primary Care Medical Clinic with ability to address the full range of
primary healthcare needs of persons with moderate to high
behavioral health risk and complexity
Food Mart
CBHOFood MartCBHO
Severe: Severe depression, severe anxiety (including PTSD), schizophrenia, bipolar disorder, schizoaffective disorder, personality disorders, SU disorder (abuse/dependence)
Serious: Schizophrenia, schizoaffectivedisorder, bipolar disorder, SU disorder (abuse/dependence)
Assignment of client populations:
Behavioral health dimension
?
Clinical Design for Adults with Low to Moderate and Youth with Low to
High BH Risk and Complexity
Primary Care Clinic with Behavioral
Health Clinicians
embedded, providing
assessment, PCP
consultation, care
management and direct
service
Partnership/Linkage with
Specialty CBHO for persons who need their care stepped up to
address increased risk and complexity with ability to step back to Primary Care
Clinical Design for Adults with Moderate to High BH Risk and
Complexity
Community Behavioral Healthcare Organization with an embedded
Primary Care Medical Clinic with ability to address the full range of
primary healthcare needs of persons with moderate to high
behavioral health risk and complexity
Food Mart
CBHOFood MartCBHO
Clinical Design for Adults with Low to Moderate and Youth with Low to
High BH Risk and Complexity
Primary Care Clinic with Behavioral
Health Clinicians
embedded, providing
assessment, PCP
consultation, care
management and direct
service
Partnership/Linkage with
Specialty CBHO for persons who need their care stepped up to
address increased risk and complexity with ability to step back to Primary Care
Clinical Design for Adults with Moderate to High BH Risk and
Complexity
Community Behavioral Healthcare Organization with an embedded
Primary Care Medical Clinic with ability to address the full range of
primary healthcare needs of persons with moderate to high
behavioral health risk and complexity
Food Mart
CBHOFood MartCBHO
Your current outpatient services:
Do you have client populations that could be served in primary care?
How many of your staff could be stationed at a PCP office?
Your rehabilitation services:
Do you have client populations that could be served in primary care?
Your current PCP services:
With proper support, could they serve additional client populations?
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The Four Quadrant Clinical Integration Model
Quadrant II
BH PH
Behavioral health clinician/case manager w/ responsibility for coordination w/ PCP
PCP (with standard screening tools and guidelines)
Outstationed medical nurse practitioner/physician at behavioral health site
Specialty behavioral health Residential behavioral health Crisis/ED Behavioral health inpatient Other community supports
Quadrant IV
BH PH
PCP (with standard screening tools and guidelines)
Outstationed medical nurse practitioner/physician at behavioral health site
Nurse care manager at behavioral health site
Behavioral health clinician/case manager
External care manager Specialty medical/surgical Specialty behavioral health Residential behavioral health Crisis/ ED Behavioral health and
medical/surgical inpatient Other community supports
Be
ha
vio
ral H
ealt
h (M
H/S
A) R
isk
/Co
mp
lex
ity
Quadrant I
BH PH
PCP (with standard screening tools and behavioral health practice guidelines)
PCP-based behavioral health consultant/care manager
Psychiatric consultation
Quadrant III
BH PH
PCP (with standard screening tools and behavioral health practice guidelines)
PCP-based behavioral health consultant/care manager (or in specific specialties)
Specialty medical/surgical Psychiatric consultation ED Medical/surgical inpatient Nursing home/home based care Other community supports
Physical Health Risk/Complexity
Persons with serious mental illnesses could be served in all settings. Plan for and deliver services based upon the needs of the individual, personal choice and the specifics of the community and collaboration.
Low High
Lo
w
Hig
h Assignment of client
populations:
BH and Medical dimensions
14
15
16
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Clinical Design for Adults with Low to Moderate and Youth with Low to
High BH Risk and Complexity
Primary Care Clinic with Behavioral
Health Clinicians
embedded, providing
assessment, PCP
consultation, care
management and direct
service
Partnership/Linkage with
Specialty CBHO for persons who need their care stepped up to
address increased risk and complexity with ability to step back to Primary Care
Clinical Design for Adults with Moderate to High BH Risk and
Complexity
Community Behavioral Healthcare Organization with an embedded
Primary Care Medical Clinic with ability to address the full range of
primary healthcare needs of persons with moderate to high
behavioral health risk and complexity
Food Mart
CBHOFood MartCBHO
18
Healthcare Homes for SMI Adults
Question: Can a typical Primary Care Clinic serve as a successful holding environment for adults with Serious Mental Illness?
Primary Care Services embedded in a CBHO is an important strategy for addressing the health disparities for the SMI population.
19
Clinical Design for Adults with Moderate to High BH Risk and
Complexity
Community Behavioral Healthcare Organization with an embedded
Primary Care Medical Clinic with ability to address the full range of
primary healthcare needs of persons with moderate to high
behavioral health risk and complexity
Food Mart
CBHO
Task 2:
Retooling our clinical approach and skills.
a. Delivery system design: Who is on the health care team and how do we coordinate our clients’ care?
b. Clinical decision support: What is the best care and how do we make it happen every time?
c. Self-care management:How do we help clients live with their conditions?
d. Clinical information systems: How do we capture & use critical information to improve clinical care?
E. Wagner, Group Health
Good outcomes (clinical, satisfaction, cost, and function) result from productive interactions. To have productive interactions the system needs to develop four areas at the level of the practice:
Chronic Care Model
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IMPACT program – Doubling the effectiveness of usual care for depression. How was this achieved?
A robust online client tracking system/registries to ensure better clinical outcomes, reduce medical costs and waste.
Person-Centered HomeDelivery system
Decision-supportSelf-management
Clinical information system
Application of elements of the Chronic Care Model:
Collaboration and coordination:A care team consisting of a PCP and Behavioral Health Specialist/Care
Coordinator, in consultation with psychiatrist when needed.
One home with stepped care option
Clinical guidelines and evidence-based practices are embedded in daily practice:
Use of screening tools, flow sheets as reminders, and standardized intervention modules
Self-management training opportunities, Education, joint decision making
Behavioral health services in primary care settings
The patient's primary care physician works with a care coordinator to develop and implement a treatment plan (medications and/or brief, evidence-based therapy).
Person-centeredDelivery design systemClinical decision support
Self-managementClinical information system
Example of a service approach
Cont’d
Proposed Flow:
Care coordinator and primary care providers consult with a designated prescriber when needed.
Care Coordinator (nurse, social worker or psychologist):
• Educates the patient about mental health conditions;
• Supports psychiatric medication therapy prescribed by the patient's primary care provider if appropriate;
• Coaches patients using Behavioral Activation, Motivational Interviewing ,or other relevant counseling techniques;
• Offers a brief (six-eight session) course of evidence-based counseling, such as Problem-Solving treatment (PST) or Cognitive Behavioral Therapy;
• Monitors symptoms for treatment response;
• Completes a relapse prevention plan with each patient who has improved;
Cont’d
The IT system contains rating scales/screening tools that enable care coordinators to track and monitor clinical improvement.
Psychiatrist consults with the care coordinator and primary care physician on the care of patients who do not respond to treatments as expected.
The Care coordinator measures symptoms at the start of a patient's treatment andregularly thereafter using brief, structured screening and clinical rating scales thatare appropriate for the specific disorders that are being treated. (PHQ-9 (for depression), GAD-7 (for anxiety disorders), GAIN-SS (GAIN SDScr) (for chemical dependency)
Stepped care:Treatment is adjusted based on clinical outcomes and according to evidence based treatment algorithms and principles
Aim for a 50 percent reduction in symptoms within 10-12 weeks If client is not significantly improved at 10-12 weeks after the start of a treatment plan, change the plan (increase of medication dosage, a change to a different medication, addition or change of psychotherapy, a combination of medication and psychotherapy, or other treatments suggested by the team psychiatrist).
Washington State GA-U Project Clinical Flow
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New Patient’s first Visit to PCP includes
behavioral health screening
Possible BH Issues?
Behavioral Health Assessment by BH
Professional working in primary care
Need BH Svcs?
Clients with Low to Moderate BH need enrolled in Level 1; to be case managed and served in primary care by PCP and BH Care Coordinator with support from Consulting Psychiatrist and
other clinic-based Mental Health Providers
Clients with Hi Moderate to High need referred to Level 2 specialty care; PCP continues to
provide medical services and BH Care Coordinator maintains linkage; this is a time-
limited referral with expectation that care will be stepped back to primary care
YES
YES
Person Centered Healthcare Home Clinical Design based on IMPACT Model- Systematic outcomes tracking (e.g., PHQ-9 for depression, GAD-7 for anxiety) - Treatment adjustment as needed including stepped care (e.g. up to specialty BH) (based on clinical outcomes, evidence-based algorithm; in consultation with team psychiatrist)- Relapse prevention
Referrals to other needed services and supports (e.g. CSO, Vocational Rehabilitation)
Physical health monitoring of SMI clients:
1. Assure regular screening and tracking at the time of psychiatric visits for all behavioralhealth consumers receiving psychotropic medications—check glucose andlipid levels, blood pressure, weight ,and Body Mass Index (BMI).
2. Record and track changes and response to treatment and use the information toobtain and adjust treatment accordingly.
Services in CBHOs (for moderate to severe client populations)
Person-centeredDelivery design systemClinical decision support
Self-managementClinical information system
Example of a service approach
Care Team and care coordination
Evidence-based treatment – with decision support:Cognitive Behavior Therapy
(depression, anxiety)Motivational InterviewingDialectic Behavioral TherapyTrauma therapy
Outcome-based: Validated assessment tools: pre- and post
Self-management support
Referral, with coordination of care, to primary care, level I S/U outpatient services (including ambulatory detoxification), medication assisted treatment.
Clinical Information System (registry system)
Stepped Care
Care Team and care coordination
Evidence-based treatment – with decision support:Cognitive Behavior Therapy for psychosis Motivational InterviewingCo-occurring disorder treatmentPACTRecovery coachingFamily psycho-educationSupported educationSupported employmentSupported housingTrauma therapy
Outcome-based: Validated assessment tools: pre- and post
Person-centeredDelivery design systemClinical decision support
Self-managementClinical information system
Services in CBHOs (for severe to serious client populations)
Example of a service approach
Cont’d
Self-management support:
Illness self-management (an evidence based program)Peer SupportPeer-run programs, i.e. Clubhouse
Referral, with coordination of care, to primary care, level I S/U outpatient services (including ambulatory detoxification), medication assisted treatment.
Clinical Information System (registry system)
Stepped Care
Physical health monitoring:
1. Assure regular screening and tracking at the time of psychiatric visits for all behavioralhealth consumers receiving psychotropic medications—check glucose andlipid levels, blood pressure, weight ,and Body Mass Index (BMI).2. Record and track changes and response to treatment and use the information toobtain and adjust treatment accordingly. 3. Medical nurse practitioners/ primary care physicians located in behavioral health.4. A primary care supervising physician.5. An embedded nurse care manager.6. Identify the current primary care provider for each individual and assure coordination.7. Provide education.8. Wellness programs.
Possible challenges experienced by clinical staff
• We’ve always done it this way. Why change?• It will replace my clinical judgment.• I don’t have time for it.• It will lead to “cookbook practice.”• It’s too difficult.
Forming a care team versus working in silos
Coordinating care
Incorporating evidence-based practices, creating and using standardized work modules:
Basing treatment on clinical outcomes and according to evidence based treatment algorithms and principles.
Cont’d
Possible challenges (cont’d)
Moving into a role of shared expertise with the client
At least 50% of clients leave the office without understanding what they were told.
Participatory decision making occurs in about 25% of office visits.
Creating an IT system that contains rating scales/screening tools and enables care coordinators to track and monitor clinical improvement.
SummaryPrimary Care/Behavioral Healthcare Integration presents exciting opportunities:
Transforming a system that is essentially fragmented and reactive, to one that is integrated and proactive, by:
1)Establishing a collaborative continuum between PCP, mental health and substance use providers:
Person-Centered Healthcare Home
2)Retooling our clinical skills and processes:
IMPACTChronic Care Model Various applications in PCP and BHCO practices
Questions or Comments?