2009 06 09 Introduction To Integrated Care

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About Marillac Clinic - Grand Junction, Colorado
Clinic Eligibility
• 200% of federal poverty level
• Mesa County residents
• Medical program serves
uninsured ages 18-64
• Dental program serves uninsured,
CHP+, and Medicaid.

Published in: Health & Medicine, Business
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2009 06 09 Introduction To Integrated Care

  1. 1. Where Two Great Rivers Meet: Evolution of Integrated Care Steve Hurd, Ph.D. steve.hurd@stmarygj.org 970.244.2235
  2. 2. Marillac Clinic Bridging the healthcare gap
  3. 3. Clinic Eligibility • 200% of federal poverty level • Mesa County residents About • Medical program serves Marillac uninsured ages 18-64 Clinic • Dental program serves uninsured, CHP+, and Medicaid. No age limitation.
  4. 4. Prevalence Comparisons Marillac Clinic vs. PHQ 3000 Major Depression Anxiety Panic Disorder About Alcohol Marillac Binge Eating Clinic Any Diagnosis 0% 15% 30% 45% 60%
  5. 5. Integrated Care
  6. 6. Guiding Philosophy: Meeting several patient needs in one visit results in greater efficiency for both patient and Integrated provider. Care
  7. 7. 5. Close Collaboration in a fully integrated system 4. Close Collaboration in a partly integrated system 3. Basic on-site Collaboration 2. Collaboration Integrated at a distance Care 1. Minimal collaboration McDaniel, Hepworth, and Doherty (1992)
  8. 8. Integrated Care
  9. 9. $ • Financial investment at start-up. $ $ $ • Incentives to participate in $ $ office visit collaborative care services: $ • Single fee for entire • Reduced group fees Integrated • “Carving-in” diverse funding sources Care removes barriers to care. $
  10. 10. •1 Medical Director—Physician • 3 Physician Assistants • 2 Nurse Practitioners • 3+ FTE counselor positions • Family Therapist • 2 Licensed Social Workers Our • Case Manager • Psychiatric Nurse Staff • Psychiatrist - 8 Hours Weekly
  11. 11. Location Location Location Lessons Learned
  12. 12. Location Location Location Having mental heath and medical providers in adjacent Lessons offices is essential. Learned
  13. 13. Family Therapist Addictions Case Psychologist & Psychiatrist Counselor Manager Medical Medical Exam Exam Rooms Rooms Medical Provider Medical Medical Exam Stations Exam Rooms Rooms Bathroom Lessons Medical Medical The Exam Rooms Medical Assistant Exam Rooms Bathroom Learned Stations Medical Medical Rule Exam Rooms Exam Rooms Reception Front Office
  14. 14. Enhanced Record Keeping Lessons Learned
  15. 15. Enhanced Record Keeping All providers work from the same medical record Lessons Crucial for Integrated Care: Learned • Face-sheet • Mental health flowsheet • Health history questionnaire
  16. 16. Case Management Lessons Learned
  17. 17. Essential for helping Case Management patients access community resources Assists providers Lessons to stay on schedule Learned
  18. 18. Shared Success Fosters Trust Lessons Learned
  19. 19. Shared Success Fosters Trust Improved patient outcome becomes the single most important source of Lessons encouragement for functioning Learned as a single team.
  20. 20. Collegiality rather than Hierarchy
  21. 21. Collegiality rather than Hierarchy Lessons Learned
  22. 22. Collegiality rather than Hierarchy Medical and mental health providers have equal status Lessons within the team. Learned
  23. 23. Community Collaboration: Inter-agency referral agreements Marillac Clinic Colorado Local Lessons West Mental Health Hospital Learned Community Violence & Medical Addictions Clinics Agencies
  24. 24. Usage of St. Mary’s Services by Marillac’s Integrated Care Patients Hospitalization E.R. Visit 30.0% 22.5% Outcomes 15.0% 9.00% 8.00% 8.00% 7.5% 6.00% 4.00% 0% Year 1 Year 2 Year 3 Year 4 Year 4.5
  25. 25. Usage of St. Mary’s Services by Marillac’s Integrated Care Patients Hospitalization E.R. Visit 30.0% 22.5% Outcomes 15.0% 9.00% 8.00% 8.00% 7.5% 6.00% 4.00% 0% Year 1 Year 2 Year 3 Year 4 Year 4.5
  26. 26. Usage of St. Mary’s Services by Marillac’s Integrated Care Patients Hospitalization E.R. Visit During year 4, only 17% of hospital admissions were for 30.0% mental health or substance 22.5% abuse conditions Outcomes 15.0% 9.00% 8.00% 8.00% 7.5% 6.00% 4.00% 0% Year 1 Year 2 Year 3 Year 4 Year 4.5
  27. 27. Change in Hospitalization Rate (per 1,000) for All Marillac Integrated Care Patients Jan-April 2003 Jan-April 2004
  28. 28. Psychiatry Length of Stay January - April 2003 versus 2004
  29. 29. Psychiatry Charges: Jan – Apr 2003 versus Jan – Apr 2004
  30. 30. Stepped Care
  31. 31. Stepped Care Step 1 Screening, diagnostic, and preventative services; parental education
  32. 32. Stepped Care
  33. 33. Stepped Care Step 2 Active treatment in primary care, involvement of care- giver and allied health professional to prevent relapse
  34. 34. Stepped Care
  35. 35. Stepped Care Step 3 Psychiatric consultation at the primary-care setting when emotional or behavioral problems persists or complications occur
  36. 36. Stepped Care
  37. 37. Stepped Care Step 4 Referral to specialty setting for highly complex presentations or poor outcomes occur at Step 3
  38. 38. Stepped Care Step 4 Referral to specialty setting for highly complex presentations or poor outcomes occur at Step 3 More complex presentations may begin at Step 3 or 4
  39. 39. Marillac Papers to date • Mauksch, L., Reitz, R. Tucker, S., Hurd, S., Russo, J., and Katon, W. Improving quality of care for mental illness in an uninsured, low-income primary care population. General Hospital Psychiatry, 2007, 29, (4), 302-309. • Mauksch, LB. Katon, W., Russo, J., Tucker, S., Walker, E Cameron, J. The content of a low income, uninsured primary care population: Including the patient perspective. Journal of the American Board of Family Practice, 2003, (16) 278-289. • Cameron, J. and Mauksch, L. Collaborative Family Health Care in an Uninsured Primary Care Population: Stages of integration. Families, Systems and Health, 2002, 20(4) 343-363. • Mauksch, L. B., Tucker, S. M., Katon, W. J., Russo, J., Cameron, J., Walker, E., & Spitzer, R. Mental illness, functional impairment, and patient preferences for collaborative care in an uninsured, primary care population. Journal of American Board of Family Practice 2001, 50(1), 41-47.
  40. 40. Marillac Clinic Bridging the healthcare gap

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