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  • 1. Integrated Primary Care Program New England Rural Health Roundtable Maryagnes Gillman October 30, 2009 Sacopee Valley Health Center
  • 2.
    • Location - Porter, Maine
    • Opened in 1976
    • Federally Qualified Health Center
    • Patients – 4,300
    • Encounters – 17,000
    • Total staff – 45
    • Serves 12 rural towns in 4 counties & two states (Maine & New Hampshire)
    • Service area population of + 20,500
    Sacopee Valley Health Center Sacopee Valley Health Center
  • 3. Sacopee Valley Health Center SVHC
  • 4. Sacopee Valley Health Center
  • 5. Sacopee Valley Health Center
    • 3 family practice physician – 2.25 FTE’s
    • 1 pediatrician – 1FTE
    • 2 physician assistant – 1FTE
    • 1 family nurse practitioner – ½ day/week
    • 1 behavioral health consultant - LCSW
    • 1 care manager – BA
    • 1 MMCPHO care manager - RN
    • 1 pediatric psychiatrist- one day/week
    • 6 mental health program staff
    Sacopee Valley Health Center Sacopee Valley Health Center
  • 6. Programs & Services at SVHC
    • Family Medical Care
    • Pediatric Psychiatry
    • Mental Health Counseling
    • Substance Abuse Counseling
    • Integrated Behavioral Health
    • Nutrition Counseling
    • Podiatry
    • Prepared Childbirth Classes
    • Community Health Education
    • Care management
    • Optometry
    • Family Planning
    • Social Services Coordination
    • Fee Discount Program
    • Patient Assistance Program (for chronic meds)
    • MaineCare (Medicaid) Enrollment Assistance
    Sacopee Valley Health Center
  • 7. The beginning
    • Sacopee Valley Health Center was founded in 1976, and had co location of mental health services beginning in 1978 with:
    • Psychiatric Social Worker
    • Alcoholism Counselor
    • Drug Abuse Counselor
    • Contracted with York County Counseling Services (became Counseling Services, Inc.)
    Sacopee Valley Health Center
  • 8. 1978-2005
    • Through the years there were several LCSWs and clinical psychologists who worked at SVHC under contract.
    • The first clinical psychologist employed by SVHC was in 1997, and Dr. Jeffrey Krebs assumed that position in 1999.
    Sacopee Valley Health Center
  • 9. Co-location at SVHC
    • This was the model used until 2004 when we began to look at a more integrated model after a staff member heard a presentation by Kirk Stroshal.
    Sacopee Valley Health Center
  • 10. Kirk Stroshal
    • BPHC funded 2 day site visit to SVHC in Fall 2004
    • Trained all staff in the rudiments of Integrated Primary Care
    Sacopee Valley Health Center
  • 11. 2004
    • Work group formed to study viability of Integrated Primary Care at SVHC
    • Work group members from every department of the Health Center
    • Goal – clinical efficacy and financial/fiscal viability
    Sacopee Valley Health Center
  • 12. Work Team 2004
    • Director of Mental Health Services
    • Finance Billing Staff
    • Medical Director
    • Director of Allied Health Services
    • Front Office Staff
    • Administrative Secretary
    • Executive Director
    Sacopee Valley Health Center
  • 13. Integrated Primary Care at SVHC
    • Based on the Strosahl model of integration
    • Stroshal model – utilizes a behavioral health consultant
      • 1-3 consult visits in typical case
      • 15-30 minute visits to mimic primary care pace and promote visit volume
      • Chronic condition pathways may require additional protocol driven visits
      • Uses classes and group medical appointments to increase volume & depth of intervention
      • High risk, high need patients seen more often as part of team based mgmt plan
    • 2005 was kick off - after planning year
    Sacopee Valley Health Center
  • 14. 2005
    • Behavioral Health Consultant began seeing patients in September 2005
    • Needed to learn the role – lots to unlearn
    • Focused on self management and activation
    • Evidenced based tool kit
    • “ What do you think you can work on?”
    • Primary Care providers needed to refer patients to be seen
    • Using Codes for Health and Behavior Assessment/Intervention 96150-96155
    • Using PHQ9
    Sacopee Valley Health Center
  • 15. 2006
    • Developed standing orders for patients
      • HTN BP >140/90
      • Diabetes HbA1c >7
      • Depression PHQ9 >9
    • Patient satisfaction with program
    • Tracking provider referrals
    • Added classes to program
      • Stress reduction
      • Living well with ongoing conditions
    • BHC is housed in medical wing of the building
    • BHC schedule is on primary care provider monthly schedule
    • Member of primary care provider team
    Sacopee Valley Health Center
  • 16. 2007
    • Program continues to evolve
    • Targeted focus on diabetes
    • New providers on staff need to learn process
    • Medical providers went live with EMR
    • BHC using EMR exclusively for notes
    • Doing cold calls to patients while they are waiting to be seen
    • PHQ9 use continues
    • BHC now a direct report to medical director
    Sacopee Valley Health Center
  • 17. 2008
    • MeHAF funding awarded for program expansion
    • Add additional screening tools DUKE, SOAPP, MDQ, COMM, PSC, GAD7, CAGE-AID and PC-PTSD
    • Use laptops for patients to enter their own data regarding screening tools
    • Add care management functions to program
    Sacopee Valley Health Center
  • 18. 2008 Continued
    • Engage the shadow health care network
    • Use libraries as a spread strategy
    • Establish a patient and family council focused on integration and care delivery
    Sacopee Valley Health Center
  • 19. 2009
    • Problem Solving Treatment – Primary Care
    • Huddles
    • Warm hand offs
    • Curbside Consults
    • Screenings
    • Standing orders
    • Referral trolling
    • Role differentiation
    Sacopee Valley Health Center
  • 20. Primary success of PST is the patient learning new skills to approach problems. Give a man a fish he eats for a day; teach a man to fish and he eats for a lifetime. Sacopee Valley Health Center
  • 21. Project Team 2009 Jeffrey Krebs Donna Burke Marty Braga Jeff Ray Maryagnes Gillman Amy Richardson April Clark Sacopee Valley Health Center
  • 22. Role Differentiation BHC – Care Manager – MH Counselor
    • BHC – billable 1:1 visits
    • Care Manager – phone call follow-ups, shadow health care network, libraries, meets with new patients, CPEs, well child checks, Pt and Family Council
    • MH Counselor – traditional mental health counseling
    Sacopee Valley Health Center
  • 23. 2005-2009
    • Ongoing staff training
      • During interview process for potential hires
      • All staff meetings
      • Individualized team meetings
      • Methodologies have included
        • Written materials
        • Didactic presentations
        • Role play
        • Outside experts
    Sacopee Valley Health Center
  • 24. Philosophy of Integration
    • Holistic
    • Routine part of care – connecting head to body
    • Focused on wellness
    • Self management
    • Communication
    Sacopee Valley Health Center
  • 25. Patient Satisfaction Sacopee Valley Health Center
  • 26. Patient Satisfaction
    • Collected since the beginning.
    • Has evolved based on our experience and information learned as part of MeHAF Quality Counts project.
    Sacopee Valley Health Center
  • 27. New Patient Satisfaction Survey Implemented Sept 1, 2009 “Give us a Grade” Sacopee Valley Health Center
  • 28. GIVE US A GRADE Integrated Primary Care
    • The staff at this facility works well together and communicates with each other about my care. 3.77= A-
    • I receive respect from the staff that provides my care. 3.85 = A-
    • I am involved in the development of my plan of care. 3.81= A-
    • As a result of receiving integrated care, I believe my health has improved and I am taking better care of myself. 3.69 = B+
    • As a result of receiving integrated care, I am better able to do my usual activities, such as work or school and recreation. 3.82 = A-
    Sacopee Valley Health Center
  • 29. Provider Satisfaction Sacopee Valley Health Center
  • 30. Quality Counts Pilot Provider Satisfaction
    • As a result of our efforts to integrate clinical care:
      • Worsened – Stayed the Same – Improved
      • 1 - 2 - 3 - 4 - 5
      • My job satisfaction has = 4.63
      • The care provided to our patients has = 4.63
      • Communication between the medical and behavioral staff regarding our patients’ plan of are has = 4.63
    Sacopee Valley Health Center
  • 31. Results Sacopee Valley Health Center
  • 32. Self Management Goal Setting Sacopee Valley Health Center *Jul 09 – Number of pts with depression increased from 562 patients to 813 patients thus the decrease in SMG Jan08 Apr08 Jul08 Oct08 Jan09 Apr09 Jul09 Patients with Diabetes 48.4% 51% 57.5 59.7 59.9 59.8 61% Patients with CVD 1.4% 24.2% 29.8 30.5% 36.8% 32.1% 31.7 Patients with Depression 20.2% 29.6 39.7 48.2 53.7 57.5 42.3*
  • 33. UDS Measure 2009 BPR
    • By 2010, increase % of adults patients, age 18 and older who have completed one PHQ9 from 12.1 % (2008 –baseline calendar year) to 25%.
    • Current results Sept 2009 = 18.3%
    Sacopee Valley Health Center
  • 34. August 2009
    • Milestones
      • Care manager meeting with new patients
      • Care manager meeting with patients scheduled for CPE’s and Well Child Checks
      • Patient and Family Council first meeting
      • BHC and Care Manager meeting weekly with Medical Director
      • Revitalized classes – Zucchini Fest
    Sacopee Valley Health Center
  • 35. Zucchini Fest Sacopee Valley Health Center
  • 36. Patient and Family Council
    • First meeting held August 26, 2009
    • Council has seven members
    • Meetings facilitated by our Care Manager and Health Educator
    • Project specific assignments – lobby
    • Next Project – How would patients liked to be surveyed about satisfaction?
    Sacopee Valley Health Center
  • 37. Billing
    • LCSW providing this service
    • Using 96150-96155
      • Health and Behavior Assessment/Intervention Codes
    Sacopee Valley Health Center
  • 38. Sacopee Valley Health Center
  • 39. Speed Bumps
    • EMR Implementation
    • Classes
    • Paradigm shifts – medical providers & BHC/Care manager and patients
    • Segue scripts – adherence
    • Over optimism – warm hands offs
    • Cold calling difficulties
    • Role clarification
    • BHC 4 visit limit
    • Not Mental Health crisis service
    Sacopee Valley Health Center
  • 40. Next Steps
    • Pain Program
      • Schedule II medications
      • Benzos
      • Sleepers
    • Insomnia - CBT
    Sacopee Valley Health Center
  • 41. We believe that we have come a long way in putting head back on the body and treating the whole person! Sacopee Valley Health Center
  • 42. Questions? Sacopee Valley Health Center
  • 43.
    • Sacopee Valley Health Center
    • 70 Main Street
    • Porter, Maine 04068
    • Mailing address: PO Box 777
    • Parsonsfield, ME 04047
    • Contact:
    • Maryagnes Gillman – [email_address]
    • 1-207-625-8129 ext 164
    Sacopee Valley Health Center

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