introduction to integrated health · 2017. 9. 22. · lehigh/northampton county team montgomery...

Introduction to Integrated HealthChristine Hunsberger, M.Ed, NCC, LPC

Holly Karalus, MSW, PCHA

Carolyn Lewis, PsyD

Stacey Marie Little, MA

Beth McAlister, RN, BSN, MSHA

Donald Thompson, PhD

www.nhsonline.org

Introduction to Topic and Panel

Confidential - NHS Human Services, Inc. - Not for Reproduction

Rates of Chronic Physical Illness

among Individuals with SMIPeople with SMI die, on average, 25 years

earlier than the general population

Increased mortality and morbidity are largely related to preventable conditions

Cardiovascular Disease

Diabetes, respiratory diseases, infectious diseases


Higher Rates of Risk Factors

Smoking

Alcohol Consumption

Poor nutrition/obesity

Lack of exercise

IV drug use

“unsafe” sexual behavior

Residence in group care facilities


Causes of Vulnerabilities

Homelessness

Trauma

Unemployment

Incarceration

Poverty

Social isolation

Impact of psychotropic medications


Impact to Access to Health Care

Patient Factors

Provider Factors

System Factors

Overuse

Underuse

Start with Assessment


Physical Health Screening Tools

Physical Health Assessment-

Reviews both overall physical and mental/behavioral health

concerns

SHOT- Shared Health Online Tool-

Documents number of contacts with wellness nurse, health

navigator, PCP, BMI, tobacco usage, substance abuse concerns

and if the self management toolkit is being used

WOOT- Wellness Outcomes Online Tool

Reviews the 8 domains of wellness


Health Risk Screening Tool-HRST

A web-based instrument

Screens for health risks associated with a wide variety of disabilities

Provides information about the critical planning component of

health risk.

Ensures health risks are identified, managed, and planned for in the

person centered planning process.

Provides population-wide monitoring and oversight capability on a

wide variety of critical health and behavioral issues

Data trending, health tracking, self auditing and retrospective

analysis

Specific Programs and

Interventions


Behavioral Health Liaison

Wellness Nurse as part of Targeted Case Management

Department Responsibilities

Physical Health Screenings

Connection between PCP/specialists and

Psychiatrist/Outpatient Department

Attends PCP/specialist appointments

Provides Smoking Cessation classes

Developed Personal Wellness Plans


Supports- Peer Wellness Coaching

Peer Specialist Trained as Wellness Coaches

Create Wellness plans with individuals in one of

the 8 domains of wellness

Uses Wellness Toolkit to assist with goal

development

Coordinates with Wellness Nurse


Cap Region Nurse Navigator

Requirements

chronic health condition, be over the age of 18, and receive Behavioral Services at NHS Capital Region

Services provided

Health Education

Assessments

Person Centered Service Plans

Referral Support and Collaboration

Transportation

Medication Management

Routine screening reminders


Wellness Recovery Teams

A team of professionals working together to support an individual in

the community to meet their identified wellness goals to include

both Behavioral Health and Physical Health Illnesses

Administrative Navigator

Behavioral Health Navigator (Masters Level)

Nurse Navigator (Registered Nurse)

Admission Criteria:

Severe and Persistent Mental Health Diagnosis

18 years of age or older

Co-occurring physical health illness



Length and frequency of service depends on the needs

of the individual

Teams provide outreach and coordination with all

physical health and behavioral health providers

involved with the individual in care.

Teams assist individuals in reaching their wellness goals



Outcomes

• Decreased utilization of crisis services

• Increase in overall health, decrease in physical

health complications

• Decrease in use of emergency rooms

• Reduction in hospitalization for both behavioral

health and physical health

• Increased satisfaction and quality of life

Lehigh/Northampton County Team

Montgomery County Team

Montgomery County HCHC

www.nhsonline.org


Health Choices Health Connections

Regional pilot program in PA

SMI and co-occurring physical health concerns

Designed with key concept of recovery

Members encouraged and empowered to work as part of

a team

Navigators focus on an individual’s whole health

physical health needs, mental health needs, and social

support needs.


What do HCHC Navigators do?

Create a whole health treatment plan that is

individualized for each consumer

Make sure each individual has a Primary Care Provider

Focus on each individual’s total wellness

Help individuals recover and become resilient

Support individual’s independence


What Are Specific Interventions?

Educating individuals and family/friends

Offering emotional support or assistance in finding

outpatient services to address mental health needs

Helping with medication management

Linking individuals with other community resources that

may help them stay on track with treatment or improve

their quality of life


HCHC Specific Interventions

Assisting in communication with doctors and acting as a

liaison with other medical professionals

Offering aid in setting up and getting transportation to

appointments

Explaining insurance issues and helping with paperwork

Providing basic nutritional advice; helping individuals

learn to food shop on a budget


What Are The Benefits?

Improved understanding of medications.

Improved self-management and wellness strategies

Development of improved relationship skills.

Increased confidence and an understanding of how to

negotiate and communicate with health care providers.

Increased coordination of care.


What Makes the Montgomery

County Team Unique?

Team approach

Staffing

Transportation services

Collaborative meetings



County Team Unique?

Use of the Consumer Health Inventory (CHI)

Screens, monitors and assesses the progression of

health problems and concerns

Follow-up administrations can inform about changes

in a person’s health and well-being.

Tool of communication between the Navigator and the

individual.



County Team Unique?The creation of preferred provider list

Local medical professionals that work best with the

population of individuals we serve

Allows the building of relationships with doctor’s

offices which increases continuity of care

Includes cardiologists, dentists, dermatologists,

nutritionists, podiatrists, urologists, Ob-Gyn, etc.


Most Common Areas of

InterventionDepression

Bipolar Disorder

Stress, Anger concerns, and Anxiety

Diabetes

Hypertension

Heart Disease

Drugs and Alcohol

Poor Nutrition

Exercise and Lifestyle Needs/ Weight loss & Weight gain

Pregnancy

Tobacco Cessation

Health Home with Integrated

Primary Care


Co-located Primary Care

Fairmount Primary Care• Federally Qualified Health Center satellite,

• History of serving individuals in poverty and

insured through publicly funded means - Medicaid,

Medicare, etc.

• Invested in developing integrated primary and

behavioral healthcare.


Staffing of Primary CareSharon Hill Medical

Primary care staff on-site at NHS 5 days/week

Medical Director - family practice physician

Nurse Practitioner/Physician Assistant

Medical Assistant


On-site Pharmacy Services

Life Tree Pharmacy services available to all

participants

Coordination of medication therapy with

prescribers and other professional staff

Immediate medication prescriptions fills

Medication therapy adherence monitoring


Staffing of Integrated Care Model Health Home Team consists of:

Participating individuals in recovery

Psychiatrists

Primary care professional staff (Fairmount)

Nurse Navigators (RN on each Adult BCM team or

Medical Assistants in Outpatient program)

Care Managers (Blended Case Managers)

Peer Wellness Coaches

InSHAPE Health Mentors (fitness trainers)

Yoga


Integrating Care

NHS/PCP leadership team meets every other

week.

NHS supervisors trained in integrated care

NHS case managers trained as care managers

NHS nurse navigators on each Adult BCM

team

NHS Peer Wellness Coaches


Integrating Care

Weekly care coordination meeting with on-site

primary care practice or virtual meeting with

community based primary care practice.

Shared access to EHRs for those mutually

served.

Shared collaborative care plan.


11/18/16

NHS DELAWARE COUNTY

CARE COORDINATION MEETING MINUTES Date: ___________

Care Coordination Meeting Attendees:

Indentifying and Diagnostic Information Staff Involved in Serving Individual

Name of Individual Served: Birthdate:

Behavioral Health Diagnoses:

Physical Health Diagnoses:

Psychiatrist:

Primary Care Physician/CRNP/PA:

Nurse Navigator/FACT Nurse/OP Med Asst:

Blended or FACT Case Manager:

MH Therapist:

D&A Therapist:

Psychiatric Rehabilitation:

Peer Wellness Coach:

Residential Program:

Issues of Concern and/or Successes

1.

2.

3.

4.

Medication List Action Plan

Behavioral Health:

Physical Health:

Action(s): Responsible

Parties:

Due

Date(s):

11/18/16


Integrated Care Supports

Pharmacy providing medications at time of

visit

Smoking cessation program

Whole Health Action Management (WHAM)

groups

InSHAPE program

Health Event sessions provided monthly

Lunch and Learns

Annual Health Fair open to community


Integrating Care

Community-based primary care practices

Nurse navigators key to communication

Care coordination through Health Information

Exchanges - NHS Delaware County was one of

the first three behavioral health members of

HealthShare Exchange of Southeastern

Pennsylvania (HSX).


Role of MCO in Integration Effort

Magellan Behavioral Health

• Supportive of effort throughout

• Agreed to expansion of nurse navigator staffing

• Worked with NHS to develop psychiatric

consultation procedure code and reimbursement

rate

• Conducting the analysis of hospitalization rates as

an outcome indicator for the health home


Summary


Questions?