Michigan Primary Care Association Webinar3/13/12                Evaluating the integrated                approach to chron...
Cherry Street Health Services(CSHS)   Not-for-profit 501(c)(3) federally qualified    health center (FQHC)   Established...
CSHS Merger   On October 1, 2011 CSHS merged with two    behavioral health organizations     Touchstone Innovare     Pr...
Touchstone Innovare   Private, non-profit, 501(c)(3) corporation    formed in 1998   Outpatient Services for individuals...
Proaction Behavioral HealthAlliance   Private, non-profit 501(c)(3) corporation originally    established in 1968 as Proj...
The new Cherry Street HealthServices   Largest not-for-profit FQHC in Michigan   Over 800 employees   Now provides a wi...
Heart of the City Health Center   Hallmark of “One Person. One Place. One    Solution” motto   One location for all of a...
Durham Clinic   One of the seven different clinics located in the    Heart of the City Health Center   Opened October 3r...
Durham Clinic – Mission   Purpose –        “To help individuals manager their chronic health        conditions, so their...
Durham Clinic – MissionChronic Care   Focus on chronic health conditions     Any  health condition that requires continu...
Durham Clinic – MissionPatient Activation   Get the patient involved in their health care       An educated patient is a...
Durham Clinic – MissionLessen Impact of Illness   Goal: Reduce symptoms, ameliorate illness     But   this isn’t always ...
Durham Clinic – Who we areOur Patients   A mix of clients from Touchstone and previous    Cherry Street patients   Total...
Durham Clinic – Who We Are   Clinical Staff    2  Internal Medicine Physicians (1 FTE)     1 Psychiatrist (0.5 FTE)    ...
Durham Clinic – What We DoProviders   Provider Roles       Physician, psychiatrist, nurse, medical assistant           ...
Durham Clinic – What We DoHealth Coaching   Tools:     Licensed    outpatient therapists       CBT,   DBT, etc.     Ex...
Durham Clinic – What We DoCoordination of Care   Morning meetings       All clinicians meet to discuss patients coming i...
Durham ClinicOrigins - IDT   Development of Durham     “Integrated   Development Team” (IDT)       Pilotprogram       ...
EvaluationOrigins – Pilot Study   Pilot study design       13 IDT patients       Methods:           Surveys           ...
CIT Evaluation   Chronic Illness Treatment: An Integrated Approach    (CIT) is:        A quasi-experimental study design...
CIT EvaluationMethods - Participants   Population       All over 18 years of age       One or more chronic health condi...
CIT EvaluationMethods - Measures   Health data     Blood pressure (each visit)     Body Mass Index (BMI) (each visit)  ...
CIT EvaluationMethods - Measures   Service Utilization data     Frequency  and cost of services received during      the...
CIT EvaluationMethods - Measures   Survey Data     English and Spanish versions     Validated, industry standard questi...
CIT EvaluationMethods - MeasuresPatient Health Questionnaire•                                             General Anxiety ...
CIT EvaluationMethods - MeasuresClinical Global ImpressionScale – Schizophrenia (CGI-   Brief Pain Inventory (BPI)SCH)   ...
CIT EvaluationMethods - MeasuresCAGE-AID                        EQ-5D   Screen for alcohol and         Health outcome/he...
CIT EvaluationMethods - Measures   Patient Activation Measure 13 Item (PAM-13)     Knowledge, skill, and confidence of m...
CIT EvaluationMethods - Analysis   Data will be analyzed at the end of the 3 year    data collection period     Analysis...
Expected Results  5                           •   If the Durham Clinic is4.5                               successful, we ...
So what?   If the data shows that Durham works: Expand!     2ndfloor behavioral health wings     Peds?     And beyond…
Strengths andLimitations/ChallengesHeart of the City Health Center   Treatment/Comparison groups in same    building    ...
Strengths andLimitations/ChallengesSimultaneous Evaluation and Clinic development Growing pains – not everything goes as ...
Strengths andLimitations/ChallengesMerger and Organization   Logistics       Changing regulatory (e.g. IRB) documents   ...
Evaluating the Integrated Approach to Chronic Care Management
Evaluating the Integrated Approach to Chronic Care Management
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Evaluating the Integrated Approach to Chronic Care Management

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This webinar will provide an overview of the evaluation study being done at the Durham Clinic, an integrated health home run by Cherry Street Health Services in Grand Rapids, Michigan. The study seeks to determine whether the delivery of health care through a multi-disciplinary team using the chronic care management model delivers better symptom management and reduced impact of the
illness on patients’ desired functioning.

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  • Hallmark of Merger
  • Very familiar graphic
  • HbA1c – Glycated hemoglobin
  • Evaluating the Integrated Approach to Chronic Care Management

    1. 1. Michigan Primary Care Association Webinar3/13/12 Evaluating the integrated approach to chronic care management Ryan Kielbasa RyanKielbasa@CherryHealth.com Cherry Street Health Services www.CherryHealth.org
    2. 2. Cherry Street Health Services(CSHS) Not-for-profit 501(c)(3) federally qualified health center (FQHC) Established in 1988 Based in Grand Rapids with health centers in Kent and Montcalm counties Served over 50,000 individuals in 2010
    3. 3. CSHS Merger On October 1, 2011 CSHS merged with two behavioral health organizations  Touchstone Innovare  Proaction Behavioral Health Alliance
    4. 4. Touchstone Innovare Private, non-profit, 501(c)(3) corporation formed in 1998 Outpatient Services for individuals with serious psychiatric conditions:  Psychiatry  Therapy  Case Management  Psychosocial rehabiliation Served 2,900 clients in 2010
    5. 5. Proaction Behavioral HealthAlliance Private, non-profit 501(c)(3) corporation originally established in 1968 as Project Rehab Services:  Residential treatment for correctional systems  Outpatient counseling  Substance use treatment  Wellness & Prevention programs  Employee Assistance Program Approximately 176,000 outpatient encounters and 56,700 residential days per year
    6. 6. The new Cherry Street HealthServices Largest not-for-profit FQHC in Michigan Over 800 employees Now provides a wide array of services to the community New vision:  “One person. One place. One Solution.”  Focus on integration of physical, mental, and psychiatric care.
    7. 7. Heart of the City Health Center Hallmark of “One Person. One Place. One Solution” motto One location for all of a patient’s health needs  Adult Medical Clinic  Pediatric Clinic  Vision Clinic  Dental Clinic  Counseling Center  Case Management and Psychiatry  Patient Services  Patient Centered Health Home
    8. 8. Durham Clinic One of the seven different clinics located in the Heart of the City Health Center Opened October 3rd Integrated behavioral/medical health clinic  Focus is on erasing that distinction Using the Patient Centered Medical Home Model  We hope to become a certified PCMH
    9. 9. Durham Clinic – Mission Purpose –  “To help individuals manager their chronic health conditions, so their conditions do not interfere with how they want to lead their lives”
    10. 10. Durham Clinic – MissionChronic Care Focus on chronic health conditions  Any health condition that requires continued follow-up treatment, adjustment, or review  Designed to simultaneously address multiple chronic health conditions, some of which are psychiatric  Integration across all chronic health conditions  Behavioral/Physical - irrelevant
    11. 11. Durham Clinic – MissionPatient Activation Get the patient involved in their health care  An educated patient is an empowered patient Walking side-by-side  No more “Do as I tell you” paradigm  Stages of Change and Motivational Interviewing  Changing how we view patient progress  Stop thinking in terms of “resistance” and “non-compliance”  Rather, patients are “pre-contemplative” or “under-activated”  Recognizing that patients always do their best given their experiences and environments  It is the provider’s task to help patients make different choices, to become informed and activated.  Draws out intrinsic motivation, rather than pouring in
    12. 12. Durham Clinic – MissionLessen Impact of Illness Goal: Reduce symptoms, ameliorate illness  But this isn’t always 100% possible Freedom to live how they choose  Minimize hindrances from conditions From “managing the person” to “managing the illness”
    13. 13. Durham Clinic – Who we areOur Patients A mix of clients from Touchstone and previous Cherry Street patients Total population will be around 600 patients  Approx. 250 from Touchstone  Serious mental illness  Most with one or more comorbidities  Transferred directly from case management team to Durham in October  Most referred by case manager  Approx.350 from existing CSHS patients and new referrals
    14. 14. Durham Clinic – Who We Are Clinical Staff 2 Internal Medicine Physicians (1 FTE)  1 Psychiatrist (0.5 FTE)  6 Health Coaches  1 Nurse  1 Medical Assistant  2 Case Managers
    15. 15. Durham Clinic – What We DoProviders Provider Roles  Physician, psychiatrist, nurse, medical assistant  Similar to a regular practice with one exception:  They practice within the framework of an integrated team  Case Managers  Goal planning  Connect patient with community resources  “Manage the illness, not the individual” framework  Health Coaches  Licensed social workers with Master’s of Social Work degrees (LMSW)  Help patients to become informed and activated  Provide primary interventions when appropriate  E.g. Counseling support
    16. 16. Durham Clinic – What We DoHealth Coaching Tools:  Licensed outpatient therapists  CBT, DBT, etc.  Extensive education in a multitude of chronic conditions (e.g. HTN, diabetes)  Trained in Motivational Interviewing Work alongside the patient to gain insight into illness and develop strategies for positive change
    17. 17. Durham Clinic – What We DoCoordination of Care Morning meetings  All clinicians meet to discuss patients coming in that day  Coordinated strategic planning One electronic health record  Providers working together -> Chart becomes a complete, holistic view of medical history One treatment plan  All conditions treated together  The internist’s plan is the psychiatrist’s plan is the health coach’s plan…because they worked together to develop it  No PCP gatekeeper or mandated hand-offs  Everyone sees internist, health coach, nurse  One person. One place. One solution.
    18. 18. Durham ClinicOrigins - IDT Development of Durham  “Integrated Development Team” (IDT)  Pilotprogram  “Mini-Durham”  22 patients  Smaller staff  06/2010 – 10/2011
    19. 19. EvaluationOrigins – Pilot Study Pilot study design  13 IDT patients  Methods:  Surveys  Patient activation, health status, symptoms, etc.  Focus Groups  Staff  Patient Outcomes:  Quantitative data (surveys) not yet analyzed  Qualitative data showed us:  Clinical improvements  Study improvements  Confirmed: We can do this. We need to do this.
    20. 20. CIT Evaluation Chronic Illness Treatment: An Integrated Approach (CIT) is:  A quasi-experimental study design  Set to last for three years  Approved through the Michigan Department of Community Health Institutional Review board Three key questions: 1. Is it more effective to treat all of a person’s chronic health conditions together versus separately? 2. Does the integrated model incur less health care costs than treatment as usual? 3. Does health coaching for chronic health conditions increase treatment adherence?
    21. 21. CIT EvaluationMethods - Participants Population  All over 18 years of age  One or more chronic health condition  Patient at Durham Clinic or HOTC Adult Medical  Both are Cherry Street clinics Sample  600-1200 participants  300-600 in treatment group (Durham)  300-600 in comparison group (HOTC Adult)  Race, ethnicity and gender of participants is expected to be representative of the current patient population  Voluntary  Patients do not need to participate in the study in order to receive care at either clinic. Participation in study does not affect care in any way. Data collection  Health, claims, and survey data  Survey data collected every 6 months
    22. 22. CIT EvaluationMethods - Measures Health data  Blood pressure (each visit)  Body Mass Index (BMI) (each visit)  Substance Use History (each visit)  HbA1c (each physician visit – for participants with diabetes)  Glycated Hemoglobin – Average amount of sugar in blood over last few months  Lipid Panel (screen and annually)  Total cholesterol  LDL “bad cholesterol”  HDL “good cholesterol”  Triglycerides
    23. 23. CIT EvaluationMethods - Measures Service Utilization data  Frequency and cost of services received during the study and 6 months prior  Cherry Street, Touchstone, Proaction data  Insurance claims data:  Emergency department visits  Hospital admissions (psychiatric and general)  Number of no shows  Length of inpatient stays  Have not began capturing this data yet
    24. 24. CIT EvaluationMethods - Measures Survey Data  English and Spanish versions  Validated, industry standard questionnaires:  PHQ-9 (Depression)  GAD-7 (Anxiety)  CGI-SCH (Psychosis)  BPI (Pain)  CAGE-AID (Substance use disorder)  EQ-5D (Perceived Health Status)  PAM-13 (Patient Activation)
    25. 25. CIT EvaluationMethods - MeasuresPatient Health Questionnaire• General Anxiety Disorder 7-9-item (PHQ-9) item (GAD-7) Screen for depression as well  Originally to diagnose as monitor and assess GAD, but also works well as severity screener for panic, social “Over the last 2 weeks how anxiety, and PTSD (Source: PHQScreeners) often have you been bothered by any of the following  “Over the last 2 weeks how problems?” often have you been bothered by any of the following • Ex. “Little interest or pleasure in doing things” problems?”  Not at all • Ex. “Trouble relaxing”  Several days  Not at all  More than half the days  Several days  Nearly every day  More than half the days  Nearly every day
    26. 26. CIT EvaluationMethods - MeasuresClinical Global ImpressionScale – Schizophrenia (CGI- Brief Pain Inventory (BPI)SCH) Illness severity and  Chronic pain degree of improvement in schizophrenia  Assesses: Assesses symptom  Level of pain groups  Positive  Relief from  Negative treatment  Cognitive  Interference with  Depressive activity Filled out by psychiatrist following clinical interview
    27. 27. CIT EvaluationMethods - MeasuresCAGE-AID EQ-5D Screen for alcohol and  Health outcome/health drug abuse status Four questions:  Descriptive profile:  Cut down use  Mobility  Annoyed by criticism  Self-Care  Guilty about use  Usual Activities  Eye-opener  Pain/Discomfort Widely validated for  Anxiety/Depression identifying alcohol abuse  Patient’s perceived  Score of 2+ health state  Eye-opener  0-100 “thermometer”
    28. 28. CIT EvaluationMethods - Measures Patient Activation Measure 13 Item (PAM-13)  Knowledge, skill, and confidence of managing one’s own health (Patient Activation)  Goes along with Stages of Change model  13 statements  “I know what each of my prescribed medications do”  Four level Likert-type scale  Disagree Strongly | Disagree | Agree | Agree Strongly  N/A
    29. 29. CIT EvaluationMethods - Analysis Data will be analyzed at the end of the 3 year data collection period  Analysis of variance (ANOVA)  Group x Time
    30. 30. Expected Results 5 • If the Durham Clinic is4.5 successful, we will see a 4 significant interaction between group and time.3.5 3 • I.e. As time progresses, we2.5 expect to see the two groups Treatment 2 differ in their outcomes –1.5 where positive outcomes are Compariso 1 n greater in the treatment group.0.5 0 • Significant time effect likely since patients in both groups t6 t1 t2 t3 t4 t5 Baseline are getting some form of care. • Group effect unlikely – We do not anticipate that the groups will differ in their baseline
    31. 31. So what? If the data shows that Durham works: Expand!  2ndfloor behavioral health wings  Peds?  And beyond…
    32. 32. Strengths andLimitations/ChallengesHeart of the City Health Center Treatment/Comparison groups in same building  Convenient!  Comparison group was initially off-site  Lower need for study staff  Increased recruitment potential  Providers work in both clinics  Internists  Patients switching from one clinic to another  Dropped from study
    33. 33. Strengths andLimitations/ChallengesSimultaneous Evaluation and Clinic development Growing pains – not everything goes as planned  Serious delays with the evaluation Logistics – not everything was planned  Studywas designed before we moved into HOTC; difficult to plane where/how surveys would be administered, etc. Tailor evaluation to specifically measure target improvement areas  Unbiased: The study was designed before we knew our clinical strengths/weaknesses. Keeps us honest.
    34. 34. Strengths andLimitations/ChallengesMerger and Organization Logistics  Changing regulatory (e.g. IRB) documents  Ti  Cherry Street  Comparison site switch  Delay Large pool of patients  Durham not possible without it CSHS executive administration  VERY open to progress and research Existing research department  Durham study independent of research department but provided consultation and resources we otherwise wouldn’t have had
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