partner with others make a greater impact · 10/29/2018 4 the state of behavioral health one in...
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10/29/2018
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Improving Access and Outcomes through Virtual Behavioral Health Integration into
Primary Care
Kate Rising, LPC
Crystal Shirley, LCSW
IMPROVE HEALTH FOR MORE PEOPLE
MOVE BEYOND BORDERSPARTNER WITH OTHERS
MAKE A GREATER IMPACT
Now is the time to …
Carolinas HealthCare System Is …
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Objectives
• Understand how care delivery systems focused on telehealth, virtual care, and skill optimization are driving access to behavioral health services in a financially sustainable model targeting population health.
• Understanding how standardization of screening tools and treatment algorithms are critical to improving patient care.
• Knowledge of clinical skills needed for effective Integrated Care.
• Design quantifiable metrics relative to program impact on health outcomes, symptom improvement, resource utilization and overall cost of care.
Behavioral Health Size and Scope
6 hospitals with over 110 beds | Over 60,000 Outpatients served per yr |
Over 1,000 virtual consults provided a month in 21 EDs |
BHI providing care for over 29 clinics | Over 136,000 calls received at
Call Center | Over 9,200 patients placed
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Virtual Health Defined
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Telemonitoring
Telecommunication
Teleconferencing
Teleconsultation
Telemedicine
Connecting
patientsto care.
Greater than 5.1 million encounters annually
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Benefits
Virtual Care…Not just Technology.Care is Care.
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Core Competencies
Timely
Access
Scalability
Industry
Alignment
Sustainability
Evidence Based
Population Health Management(Customized Coordinated Care)
Hom
e
Acuity/Resources
1. Mental
Health First
Aid
2. Employee
Assistance
Programs
3. Primary
Care
Integration
4. Care
Management
5. Nalaxone
Project
6. School-Based
Services
7. Medication
Assisted
Therapy
8. Outpatient
Behavioral Health (Therapy, Medication Mgmt., Injection Clinics)
9. Intellectual &
Developmental
Disabilities Clinic
1
0
1 2 34
5
6
7
8
9
1
1
10. Brain
Stimulation
Services (ECT and TMS)
11. Assertive
Community
Treatment Teams
1
2
1
3
1
4
1
5
1
6
1
7
12. Crisis Line
Call Center13. Medical Detox
14. Acute Care
Hospital (C/L and Tele-C/L)
1
8
15. Acute Care ED(Telepsych and BHPP)
16. Psychiatric ED
17. Psychiatric
Observation Unit
18. Inpatient
Psychiatric Services
1
9
2
0
2
1
19. Partial
Hospitalization
Services (Adult & C/A)
20. Substance Use
Intensive Outpatient (Adult & C/A)
21. Residential
Key
Physical Service Locations
Virtual Services Available
Rely on Community Services
The Atrium BH Continuum
Email questions to [email protected]
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The State of Behavioral Health
One in five adults suffers from a diagnosable mental disorder.
43.8 million adults experience mental illness in a given year.
Untreated mental health and substance abuse disorders cost the US $250-$500 billionper year.
$193 billion per year in lost workplace earnings due to untreated mental illness.
Even beyond the United States, mental illness is the #1 cause of disability life yearsworldwide, vastly outnumbering those caused by cardiovascular disease and cancer.
With proposer diagnosis and effective treatment, the recovery rate for patients withmental illness is 60-80%.
But in today’s environment, the effective recovery rate is only 5-10% due to such limitedresources and infrastructure.
Comorbid Behavioral Health and Chronic Medical Conditions
2006 Milliman, Inc US Health Care Study
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Why Primary Care?
• Stigma
• 70% of visits are Psycho-
Socially related
• Greater than 50% of all
psychotropics prescribed
by PCP’s
• 40,000 Suicides annually
• 45% of patients completing
suicide saw their PCP within
30 days
Psychiatry Workforce Challenges
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29-1066 Psychiatrists." U.S. Bureau of Labor Statistics. U.S. Bureau of Labor Statistics, n.d. Web. 30 Nov. 2014.
US: 40,000 PSYCHIATRISTS
• Half of all the counties in the
US don’t have a single
practicing Mental Health
professional
• Concentrated in Urban Areas
• 48% of psychiatrists are over
the age of 60
IMPACT
PCP
PatientBHP/CareManager
Consulting Psychiatrist
Other Behavioral Health Clinicians
Core
Program
Additional Clinic
Resources
Outside
ResourcesSubstance Treatment, Vocational Rehabilitation,
CMHC, Other Community Resources
New Roles
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IMPACT / Collaborative Care Model
2 year Randomized Control Trial:
1801 Adults with Depression
12 months:
• 50% reduction of depressive symptoms
45% IMPACT model 19% usual care participants
4 years• $3,300 in savings in health care spend per patient
Repeated in 80 Randomized Trials
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24-Month Health Care Costs for IMPACT Enrollees Versus Control Patients
Going Virtual
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Why Virtual?
1
Timely Access
2
Scalability
3
Sustainability
4
Industry Alignment
Behavioral Health Professional
• LCSW/LPC
Health Coach
• Bachelor level with two years’ experience
• Obtain Health Coach Certification within 1
year of hire date
Provider
• Adult Psychiatrist
• Child and Adolescent Psychiatrist
• Nurse Practitioner
Pharmacy
• Board Certified Psychiatric Pharmacist (BCPP)
Overview
The Collaborative Care Model The Team
PCP
PatientBHP/CareManager
Other Behavioral
Health
Clinicians
Additional Clinic
Resources
Outside
ResourcesSubstance Treatment, Vocational
Rehabilitation, CMHC, Other Community Resources
Consulting Psychiatrist
Virtual CHS BH Support Team
Our Model
“We’ve got your back”
Suzanne Koven is a primary care
doctor at Massachusetts General
Hospital in Boston and writes the
column "In Practice" at the Boston
Globe.
“The key to making team-based medical care work…is helping the patient feel that his or her relationship with the primary-care provider is at its center.”
What we want to
accomplish:
▪Improve early detection
▪Timely access to services
▪Reduce unnecessary referrals to
higher level of care
▪Drive cost effective & clinically
effective treatment
▪Support the Primary Care Provider
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Screening is the Driver
Treatment and Patient Engagement
Evidenced Based Treatment
Standardized tools in the PCP setting enhances
screening diagnosis, and treatment planning Patient Engagement Recovery
Process
36Email questions to [email protected]
BH Patient
PCP OfficePCP Office
Administers PHQ-9
3. PCP Appointment
1. PCP consults BH Provider
for curb side chart review
4. Post
Appointment
Call Back
Protocol
Virtual BH Support Team
PCP initiates in office
virtual visit if needed
2. Elevated PHQ-9 Scores Captured in BH Patient Registry
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Required Social Work Skills
•Social Work interventions do not take place of traditional psychotherapy, it is a missing entry point.
•Clinical skills required: • Screening and Assessment
• Brief therapeutic interventions
• Documentation and shared treatment planning
• Crisis Intervention and safety planning
Needed Knowledge
• Understanding of Population Health
• Self-management skills
• Psychopharmacology
• General understanding of common illnesses, normal health ranges, and effects of co-morbidity on mental health
• Health acronyms and jargon
• Community Resources for several counties
Virtual Practice
• Personal skills and rapport
• Adaptable to Call Center environment
• Team approach
• Communication and documentation
• Multi-tasking
• Technology
• Data Tracking
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Health Coaching
Motivational Interviewing
vBHI Health
Coaching
Sleep Hygiene
Movement
Nutrition
Stress Management
Pain Management
Substance Abuse
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vBHI Current State
vBHI by the Numbers (2017)Entry Point
14,228 Unique Patients
101,731 Patient Encounters
1,118 Patients Active Patients
21 Primary Care Practices
6 Pediatric Practices
70 Care Management Clinics
Email questions to [email protected]
Access to vBHI
2.8% CHS Care
Management
73.7% Patient Registry
23.5% Primary Care
Provider
Return on Investment
Disease
Severity
Clinical
Outcomes
Healthcare
Utilization
Cost of
Care
▼ Depression
symptoms
► Weight/BMI ▼ Inpatient Visits ▼ Overall
▼ Anxiety
symptoms
▼ HgB A1C ▼ Inpatient Days ▼ Inpatient
▼Suicide ideations ▼ Cholesterol
(Total, triglycerides,
LDL, HDL)
▲ Ambulatory Visits
(Primary/Specialty)
▼ Ambulatory
▼ ED Visits ▼ ED
▼ Avoidable ED/IP
Visits
Clinical Outcomes
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45% reduction in PHQ-9 score 58% decrease in suicide ideation
45% decrease in GAD-7 Score
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Avoidable Inpatient Care and ED Visits
▪ There was 27% reduction in avoidable inpatient
visits (from 33 visits pre- to 24 visits post-
intervention). Inpatient visits were classified as
avoidable using AHRQ Prevention Quality Indicator
(PQI) methodology
▪ There was 7% reduction in avoidable ED visits (from
621 visits pre- to 578 visits post-intervention,
p=.883)
▪ Visits were classified as avoidable using NYU ED
Algorithm (types of avoidable visits included: Non
Emergent, Emergent but PCP Treatable and
Emergent but preventable)
Email questions to [email protected]
vBHI Sustainability
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$0
$50,000
$100,000
$150,000
$200,000
$250,000
$300,000
Cost Comparison
1 FTE
1.5 FTE
4.6 FTE
Virtual Platform:
CHS Behavioral
Health Integration
Embedded:
Federally Qualified
Health Centers
Embedded:
Atrium
Health Clinic
Burke et al.; BMC Health Services Research 2013, 13:245
Next Steps
▪ Better study design for evaluating the program, possibilities include ✓ Randomized control trial: eligible behavioral health patients are randomly assigned to receiving BHI or not.
✓ Semi-quasi experimental design: patients from BHI clinics compared with clinically comparable patients from non-BHI clinics.
✓ Self-selected controls: patients who were screened but never enrolled in BHI. Due to self-selection bias, need to adjust for baseline comparability at data analysis stage. .
▪ Replacing billed charges with cost data for acute care utilization. Adjust for inflation while the study period expands across several years.
▪ Looking into secondary gains of the program, such as ✓ Appropriate diagnosing of depression among BHI clinics
✓ Appropriate referral to psychiatrists
✓ Pharmaceutical spend at BHI clinics
▪ Identify handful of factors that qualifies patients as “high-risk” for poor outcomes. Apply scoring algorithm to flag these patients at the time of care delivery
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Key Takeaways...
This work puts the patient first always – integrated into the full continuum, including prevention and community health
Standardized work in development and being refined (incl. teammate expectations and tools that need to be followed)
Utilize data analytics to drive focus and improve outcomes
Coordination is essential; expectation that as a team… we make sure this happens 100% of the time
Efforts to scale will be critical for success – we will prioritize to ensure this happens
vBHI Quarterly Webinar
Occurs the 1st Wednesday every 2 months
Contact Information:
Brandt Bettilyon
Project Manager, Carolinas Behavioral Health Collaborative