whole person care in cpaa and training overvie · “it is one thing to say with the prophet amos,...
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Cascade Pacific Action Alliance (CPAA) and AIMS Center Training Design SessionWhole Person Care in CPAA and Training Overview
Sara Barker, MPHAssistant DirectorUW AIMS Center
Annie McGuire, MS, LMHCBehavioral Science FacultyIntegrated Services Clinical LeadProvidence Medical Group SW
AIMS Center Implementations & Trainings
WA State BHI & CoCM
• Policy• Bree Collaborative• Medicaid Transformation
Training and Support• Integrated Care Training Program• Healthier WA Practice
Transformation Support Hub• Opioid Treatment Network
Largest WA State BHI Implementations• MHIP• UW Medicine• Providence ACO (4 regions)
Goal: Support Whole Person Care
Hospital
Community Behavioral Health Care
Collaborative Care
Behavioral Health Consultant or SpecialistPrimary Care Provider
Community-Based Services & Supports
Increase access to primary care in
behavioral health
Increase access to behavioral health
services in primary care
3
Regional Approaches to Integrated Care• No one approach fits all
– Arguing about the best integration model is a bit like arguing about the best religion
• Evidence-based models adapt to local settings in order to be successful
• Important principles that need to be followed in order to reach the Triple Aim:Value = Reach * Effectiveness / Cost
Principles for Evidence-Based Integration
Population-Based and Data-DrivenA defined group of patients or clients is tracked in a registry so that no one “falls through the cracks.”
Measurement-Based Treatment to Target Treatment goals clearly defined and tracked for every patient. Treatments actively changed until clinical goals are achieved.
Team-Based and Person-Centered Primary care and behavioral health providers collaborate effectively, using shared care plans.
Project 2A Crosswalk Bi-Directional IntegrationSame Elements in Bree Report & Collaborative Care
• BH provider key part of team • Systematic screening• Measurement-based behavioral health services• Population-based care • Treatment to target • Tracking patients and follow up • Evidence-based treatments • Access to psychiatry (Bree) vs. psychiatric case review
(CoCM)6
Project 2A: Primary Care Integration in Behavioral Health
• Off-site enhanced collaboration• Co-located enhanced collaboration• Co-located, integrated care
Challenge: • Emerging evidence, promising practices• Funding and sustainability 7
“Involves the systematic use of symptom rating scales to drive clinical decision making.”
Principle: Measurement-Based Treatment to Target
https://www.thekennedyforum.org/news/measurement-based-care-issue-brief8
Principle:Population-Based Care
© University of Washington
Free UW AIMS Registry: (https://aims.uw.edu/resource-library/patient-tracking-spreadsheet-example-data )
Behavioral Health Caseload Tracking
Tracking systems and registries support proactive patient engagement and active treatment strategies.
No one falls through the cracks!9
Translating Research into Practice
“It is one thing to say with the prophet Amos, ‘Let justice roll down like mighty waters,’ and quite another to work out the irrigation system.”
William Sloane Coffin
Social activist and clergyman
10
AIMS Center Training Strategies to Support Project 2A Implementation
AIMS Center Training at a Glance
Planning for Integration
In-Person Clinician Training
Coaching & Training
• Calls with clinic /org leaders to determine key areas for planning and training
• Involve primary care team and PCP
• Develop or fine-tune screening and treatment workflows
• Orientation for BH clinicians and psychiatric consultants
• Support sustainability
• Focus on BH professionals• Engaging patients and driving
active treatment to target• Using a registry to prioritize
and manage a patient caseload• Using psychiatry time
effectively or working effectively with psychiatric consultants
• Effective primary care team communication
• Emphasis on practice and active learning
• New content introduced through webinars and practiced in follow up case conference calls
• Coaching calls for BH clinicians and psychiatric providers
• Ad hoc support for PCP education & engagement
• Ad hoc support for work flow course corrections
Planning for Integration
• Organization/practice readiness and vision development
• New integrated care team roles introduction• Screening and treatment workflow mapping
and planning• Funding and sustainability discussions
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In Person Clinician Training
• BH and medical providers training in evidence-based treatment and roles
• Patient engagement and driving active treatment to target
• Using a registry for population management• Team communication and culture change
working in new settings
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Coaching and Training
• Trainer led coaching calls with integrated care team members to support practice implementation
• Clinical webinars and case conferencing• Additional skill building in problem solving
treatment and behavioral activation
15
Thank You!
Questions and Discussion
“We believe that enlightened trial and error beats the planning of flawless intellects.”
David Kelley, IDEO