Engines of Success for U.S. Health Reform?
Eric B. Larson, MD, MPHVice President for Research, Group Health Executive Director, Group Health Research Institute
Engines of Success for U.S. Health Reform?
Eric B. Larson, MD, MPHVice President for Research, Group Health Executive Director, Group Health Research Institute
Because everyone matters.
IBM Health and Social Programs Summit, October 2014
Craig Rhinehart’s Blog
Insights from NASHP Conference in Atlanta
Trick or Treating for State Healthcare Innovation Treats
http://craigrhinehart.com
This presentation is intended to serve as an introduction to the long-term care industry, including the scope, purpose and organizational structure of a typical long-term care facility.
While applicable for everyone, this like all of our presentations is specifically designed for caregivers in a long-term care environment.
2016 16th population health colloquium: summary of proceedings Innovations2Solutions
This paper will discuss the four key ideas discussed at the Colloquium that will have important ramifications as healthcare organizations seek to implement population health strategies:
1. understanding and alleviating Patient fear is Key to Patient experience
2. the Case for a new Population Health Protection agenda as a means to drive down Healthcare Costs
3. using data and technology to improve Healthcare for older adults
4. engage Consumers in Wellness-based Population Health and thrive financially
Living as Well as you Can for As Long as you CanBCCPA
Sit down buffet breakfast featuring keynote speaker Dr. Romayne Gallagher, Head Division of Palliative Care, Department of Family & Community Medicine, Providence Health Care; Clinical Professor, Division of Palliative Care, UBC
Better to Best Patient Centered Medical HomePaul Grundy
Better to best -- consensus meeting between large employers, HHS, CMS, DOD OPM, hospitals, Primary care association, AMA, healthcare plans around the elements that add value in the Patient Centered medical home. coordination of care, access to care Health information technology and payment reform.
Because everyone matters.
IBM Health and Social Programs Summit, October 2014
Craig Rhinehart’s Blog
Insights from NASHP Conference in Atlanta
Trick or Treating for State Healthcare Innovation Treats
http://craigrhinehart.com
This presentation is intended to serve as an introduction to the long-term care industry, including the scope, purpose and organizational structure of a typical long-term care facility.
While applicable for everyone, this like all of our presentations is specifically designed for caregivers in a long-term care environment.
2016 16th population health colloquium: summary of proceedings Innovations2Solutions
This paper will discuss the four key ideas discussed at the Colloquium that will have important ramifications as healthcare organizations seek to implement population health strategies:
1. understanding and alleviating Patient fear is Key to Patient experience
2. the Case for a new Population Health Protection agenda as a means to drive down Healthcare Costs
3. using data and technology to improve Healthcare for older adults
4. engage Consumers in Wellness-based Population Health and thrive financially
Living as Well as you Can for As Long as you CanBCCPA
Sit down buffet breakfast featuring keynote speaker Dr. Romayne Gallagher, Head Division of Palliative Care, Department of Family & Community Medicine, Providence Health Care; Clinical Professor, Division of Palliative Care, UBC
Better to Best Patient Centered Medical HomePaul Grundy
Better to best -- consensus meeting between large employers, HHS, CMS, DOD OPM, hospitals, Primary care association, AMA, healthcare plans around the elements that add value in the Patient Centered medical home. coordination of care, access to care Health information technology and payment reform.
Improving the Health Outcomes of Both Patients AND PopulationsCHC Connecticut
NCA Clinical Workforce Development, Team-Based Care 2019 Webinar Series
Webinar broadcast on: May 23, 2019 | 2 p.m. EST
In this webinar experts will share their journey in planning, preparing and launching a population health initiative. With the goals of impacting population health outcomes while ensuring cost effectiveness, our experts designed interventions to eliminate gaps in care, particularly among special populations.
The purpose of this Health Policy Study is to better understand adolescents’ views on what are considered core components of the medical home and identify barriers to promoting adolescent health in relation to the medical home.
In addition, this study sought to better understand the needs and challenges in providing adolescents with access to medical homes—from the perspective of both adolescents and experts in adolescent health and medical home policy. To accomplish these goals, researchers conducted focus groups with adolescents, presented these findings to experts, and gathered experts’ reactions to the adolescents’ perspectives. This report includes a detailed description of the methods used for this study, followed by a summary of key focus group findings and the expert reactions to these findings.
The Next Steps to Improving Home Health Care for Children with Medical Comple...LucilePackardFoundation
This briefing on family needs for home health care and potential workforce and policy solutions featuring the perspectives of a parent advocate, a home health care administrator, a pediatrician, and a state official.
Going Where the Kids Are: Starting, Growing, and Expanding School Based Healt...CHC Connecticut
Webinar broadcast on: June 28 | 3 P.M. EST
This webinar will address the benefits, challenges, and strategic advantages of a school based health center program from a clinical, data, quality, operational viewpoint, communications, and community engagement perspective. Experts will share the strategy for integrating oral health and behavioral health to ensure the best outcomes for patients.
Strategic Opportunities in Advanced Illness Management, Palliative Care and H...Kathy Brandt
Individuals living with a life-limiting condition often receive fragmented care and support. This workshop will explore opportunities for care and service providers as well as businesses to partner with advanced illness management, palliative care and hospice providers to provide added value to clients and patients while enhancing the sustainability of the organizations.
mHealth Israel_Incorporating the Patient Voice into Clinical Delivery Models ...Levi Shapiro
Incorporating the Patient Voice into Clinical Delivery Models for Person-Centered Care, presentation by Alan Balch, CEO, National Patient Advocate Foundation.
Patient Centered Medical home talk at WVUPaul Grundy
To employers the cost of healthcare is now a business issue and this talk is about what one large buyer IBM did to drive transformation via broad coalition with other large employers to form the Patient Centered Medical Home movement and the covenant between buyer and provider away from the garbage we now buy episodic uncoordinated disintegrated care. In the change of convenient conversation we have worked with the Primary care providers to give us coordinated, integrated, accessible and compressive care with a set of principles know as the Patient centered medical home.
A Patient Centered Medical Home (PCMH) happens when primary care healers keeping that core healing relationship with their patients step up to become specialists in Family and Community Medicine. The move is to the discipline of leading a team that delivers population health management, patent centered prevention, care that is coordination, comprehensive accessible 24/7 and integrated across a deliver system. PCMH happens when the specialists in Family and Community Medicine wake up every morning and ask the question how will my team improve the health of my community today?
All over the world three huge factors are in play that is driving the concept of Patient Centered Medical Home. They are:
1) Cost and demography
2) Information technology and data (information that is actionable will equal a demand for accountability by the payer or buyer of the care)
3) Consumer demand to engage healthcare differently (at least as well as they can their bank- on line) have a question about lab results why not e-mail?
But at its core it is a move toward integration of a healing relationship in primary care and population management all at the point of care with the tools to do just that.
Care Coordination in a Medical Home in Post-KatrinaNew OrleaTawnaDelatorrejs
Care Coordination in a Medical Home in Post-Katrina
New Orleans: Lessons Learned
Susan Berry • Eleanor Soltau • Nicole E. Richmond •
R. Lyn Kieltyka • Tri Tran • Arleen Williams
Published online: 14 July 2010
� Springer Science+Business Media, LLC 2010
Abstract This is a prospective study to evaluate ability of a
nurse care coordinator to: (1) improve ability of a pediatric
clinic to meet medical home (MH) objectives and (2)
improve receipt of services for families of children with
special health care needs (CSHCN). A nurse was hired to
provide care coordination for CSHCN in an urban, largely
Medicaid pediatric academic practice. CSHCN were iden-
tified using a CSHCN Screener. Ability to meet MH criteria
was determined using the MH Index (MHI). Receipt of MH
services was measured using the MH Family Index (MHFI).
After baseline surveys were completed, Hurricane Katrina
destroyed the clinic. Care coordination was implemented for
the post-disaster population. Surveys were repeated in the
rebuilt clinic after at least 3 months of care coordination. The
distribution of demographics, diagnoses and percent
CSHCN did not significantly change pre and post Katrina.
Psychosocial needs such as food, housing, mental health and
education were markedly increased. Essential strategies
included developing a new tool for determining complexity
of needs and involvement of the entire practice in care
coordination activities. MHFI showed improvement in
receipt of services post care coordination and post-Katrina
with P \ 0.05 for 13 of 16 questions. MHI demonstrated
improvement in care coordination and community outreach
domains. Average cost was $36.88 per CSHCN per year.
There was significant improvement in the ability of the clinic
to meet care coordination and community outreach MH cri-
teria and in family receipt of services after care coordination,
despite great increase in psychosocial needs. This study pro-
vides practical strategies for implementing care coordination
for families of high risk CSHCN in underserved populations.
Keywords Care coordination � Medical home �
Children with special healthcare needs (CSHCN) �
Title V CSHCN � Hurricane Katrina
Eleanor Soltau has relocated to Atlanta, Georgia, after her
involvement with this research.
S. Berry (&) � N. E. Richmond � A. Williams
Department of Pediatrics, Louisiana State University
Health Sciences Center, 1010 Common Street Suite #610,
New Orleans, LA 70112, USA
e-mail: [email protected]
N. E. Richmond
e-mail: [email protected]
A. Williams
e-mail: [email protected]
E. Soltau
Children’s Hospital Medical Practice Corporation,
New Orleans, LA, USA
e-mail: [email protected]
S. Berry � N. E. Richmond � A. Williams
Louisiana Office of Public Health, Children’s Special Health
Services, New Orleans, LA, USA
R. L. Kieltyka � T. Tran
Department of Pediatrics, Louisiana State University Health
Sciences Center, 1010 Common Street Suite #2710,
New Orleans, LA 7011 ...
Building the Health Workforce as We Transform the Delivery System, presented by Mary D. Naylor, PhD, RN, Marian S. Ware Professor in Gerontology, University of Pennsylvania School of Nursing
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
Follow us on: Pinterest
Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
263778731218 Abortion Clinic /Pills In Harare ,ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group of receptionists, nurses, and physicians have worked together as a teamof receptionists, nurses, and physicians have worked together as a team wwww.lisywomensclinic.co.za/
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
1. Promoting Improved Integration: An Examination of Collaborative Health Care Models Council on Advocacy and Government Relations Peter Martin, MD, MPH John Lusins, MD Marilyn Griffin, MD Margaret Balfour, MD, PhD
2. Disclosure Statement Drs. Martin, Griffin, and Balfour are all APA Public Psychiatry Fellows, sponsored by Bristol Myers-Squibb Dr. Lusins is an APA Psychiatric Leadership Fellow
4. Workshop Objectives Identify different models of integrative health care Explore the concept of the medical home and discuss how it can be incorporated into the mental health realm Examine examples of different integrative models, utilizing examples from the adult and pediatric realms, as well as discussing health care coordination models as seen in different countries and cultures Discuss various payment models to ensure the success of integrative health care
5. Collaborative Care: Overview Peter S. Martin, MD, MPH Child and Adolescent Psychiatry Fellow University of Rochester
12. Levels of Integration BASIC On-site CLOSE Fully Integrated MINIMAL BASIC at a Distance CLOSE Partly Integrated Collaboration Continuum Doherty, W. The Why’s and Levels of Collaborative Family Health Care.
14. The Four Quadrant Clinical Integration Model Quadrant II ↑ BH ↓ PH Quadrant IV ↑ BH ↑ PH Behavioral Health Risk/Status Quadrant III ↓ BH ↑ PH Quadrant I ↓ BH ↓ PH Physical Health Risk/Status Mauer, B. Behavioral health/primary care integration: The four-quadrant model and evidence-based practices
15. Mauer, B. Behavioral health/primary care integration and the person-centered healthcare home.
16. Joint Principles of the Patient-Centered Medical Home Personal physician Physician directed medical practice Whole person orientation Care is coordinated and/or integrated Enhanced access Quality and Safety Payment National Center for Medical Home Implementation
17. Suggested Resources Collins, C et al. Evolving models of behavioral health integration in primary care. Milbank Memorial Fund. 2010. http://www.milbank.org/reports/10430EvolvingCare/EvolvingCare.pdf Mauer, B. Behavioral health/primary care integration and the person-centered healthcare home. National Council for Community Behavioral Healthcare. 2009. Pautler, K., and M.-A. Gagne. 2005. Annotated Bibliography of Collaborative Mental Health Care. Mississauga, ON: Canadian Collaborative Mental Health Initiative. http://www.ccmhi.ca/en/products/documents/03_AnnotatedBibliography_EN.pdf Smith, TE and Sederer, LI. A new kind of homelessness for individuals with serious mental illness? The need for a “mental health home.” Psychiatric Services. 2009;60:528–533. http://ps.psychiatryonline.org/cgi/reprint/60/4/528
18. ReferencesCollaborative Care: Overview Doherty, W. The Why’s and Levels of Collaborative Family Health Care. Family Systems Medicine. 1995;13(3–4):275–81. Mauer, B. Behavioral health/primary care integration: The four-quadrant model and evidence-based practices. National Council for Community Behavioral Healthcare. 2006. Mauer, B. Behavioral health/primary care integration and the person-centered healthcare home. National Council for Community Behavioral Healthcare. 2009.
19. Towards Integrated Health Care in Northern WV John Lusins, MD Chief Resident WVU Department of Behavioral Medicine Morgantown, WV
20. Conflicts I owned 0.5% of Lime Medical LLC and had on-going consulting relationship. Closed as of May 13th 2011 No further conflicts
21. Theory 4 Quadrant Model Where do we fit? Two Locations Valley Community Mental Health Centers Chestnut Ridge Center
22. Valley CMHC Founded in 1969 by West Virginia University, Valley Counseling Services united with The Human Resources Association and incorporated as Valley Community Mental Health Services in 1972. Doing business as Valley HealthCare System, a nonprofit corporation. Spurred by the federal government, funds became available through the passage of the Community Mental Health Center Act of 1963, introduced by President John F. Kennedy and Valley was able to establish itself as one of 13 federally-funded mental health centers in the state in the early 1970’s.
25. Valley CMHC Services Chemical Dependency Developmental Disabilities Mental Health
26. Valley CMHC Suicide Hotline 24/7 staffing Outpatient services Daily clinics by MD’s Now NP’s with MD supervision Therapists Case Coordinators Crisis Unit ACT team
27. Valley CMHC Primary Care Over the last year, push by MD’s staffing to have FP/IM MD’s to join staff Non-compliance with out-sourced PCP appointments Immediate non-acute health concerns Coordination of care
28. Valley CMHC Added two Family Practitioners in last year 1 day/week at 4 BH locations New clinic Metabolic Program Well-received primary care visits (172) Reported increase in patient satisfaction No change in show-rate for BH 2 MD positions to NP’s
29. Chestnut Ridge Hospital Home of WVU Department of Psychiatry Free-standing hospital with 65 inpatient beds Over 50,000 outpatients seen last year
30. Chestnut Ridge Hospital Specialty Clinics Memor y Disorders Thought Disorders Sleep Disorders Geriatric Psychiatry All patients previously referred to main hospital outpatient for Primary Care needs
31. Chestnut Ridge Hospital 2010 WVU Family Medicine/Psychiatry Graduate hired to create Integrated Care clinic Thought Disorders Clinic Chronic severe mental illness with low-moderate primary care needs Patients given option of continuing care at Main Outpatient clinic vs. seen as part of scheduled clinic Care coordinated by BH Physicians and Social Workers
32. Chestnut Ridge Center Results (prelim) Patient adherence to primacy care recommendations increased: BP medications Glucose control Weight loss Patient satisfaction increased Physician satisfaction increased Decreased No-Show rate
33. Quadrant II PCP: Provides primary care services and collaborates with the specialty BH providers BH: Provide BH assessment and arrange for/deliver specialty BH services Assure case management (housing, community supports) Assure access to health care Create a primary care communication approach that assures coordinated service planning
34. Future Expand Primary Care integration to all specialty clinics Measure results at Valley and WVU Hospitalizations? Integrate FP into ACT team
35. References and Resources “Valley MCHC Annual Report”- 2010-2011 Collins, C et al. Evolving models of behavioral health integration in primary care. Milbank Memorial Fund. 2010. http://www.milbank.org/reports/10430EvolvingCare/EvolvingCare.pdf
37. “Hello Primary Care, I’m home!” An Overview of Behavioral Health and Pediatric Primary Care Integration Marilyn Griffin, MD PGY 5 Triple Board Resident APA Public Psychiatry Fellow APA Council on Advocacy and Government Relations May 18, 2011
38. Outline “Houston, we have a problem” Creative solutions Successful models Change Discussion
40. The Facts 2001: Surgeon General’s Report on Children's Mental Health indicated the mental health of children and adolescents was a public crisis
41. The Facts, Cont. ≈ 1 in 5 children in US with diagnosable mental health disorder ≈ 80% of mentally ill children are not identified or treated Suicide is the 3rd leading cause death in 10-24 yo Mental Illness is the 2nd leading cause of disability and premature mortality in the U.S. Burden of untreated mental illness on various systems of care
42. The Facts, Cont. Source: Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities (2009 pg 246). Adapted from Eisenberg and Neighbors (2007).
43. “It is easier to build strong children than to repair broken men.” Frederick Douglass
48. The Patient - Centered Medical Home 1967 AAP introduced the medical home concept 2002-2006 expanded definitions of medical home and creation of other models 2007 AAFP, AAP, ACP, AOA, developed: Joint Principles of the Patient-Centered Medical Home
49. The Patient - Centered Medical Home: Joint Principals Personal physician Physician directed medical practice Whole person orientation Care coordination/integration Enhanced access to care Quality and safety Appropriate payment National Center for Medical Home Implementation
50. The Patient - Centered Medical Home: Benefits Unique opportunity to engage in services without stigma Improved access to specialty care Appropriate level of care by providers in familiar environment
51. Bridging Medical Home and Integrated Care Patients designated for medical home care represent those potentially targeted for integrated care The medical home has the potential to shift costs from acute care to preventive, chronic care management, and recovery
52. Bridging Medical Home and Integrated Care, Cont. Medical home will provide more comprehensive approach to primary care more holistic and integrated care a more collaborative physician-patient relationship
53. Collaboration +/- Integration = Confusion Terms not used consistently in the field Engel (1977) biopsychosocial model theory at the root of collaborative and integrated care Strosahl (1998) collaborative care involves behavioral health working with primary care integrated care involves behavioral health working within and as a part of primary care (you say tomato, I say tomhato)
56. Child and Family Counseling Center (CFCC) Based on patient centered medical home model Unmet behavioral health service need Provide evaluation and treatment: Mood disorders Anxiety disorders Attention-deficit and disruptive behavior disorders Adjustment disorders http://www.chp.edu/CHP/counseling
57. CFCC Partnership Children’s Community Pediatrics Children’s Hospital of Pittsburgh Western Psychiatric Institute and Clinic
58. CFCC: Children’s Community Pediatrics 110 Pediatricians Several mid-level providers 19 practices 28 offices 8 counties http://www.cc-peds.net/main/index.shtm
59. CFCC: Children’s Hospital of Pittsburgh Only children’s hospital serving Western PA Level 1 Pediatric Trauma Center One of 8 pediatric hospitals in US named to: U.S. News & World Report's Honor Roll of America’s “Best Children’s Hospitals” for 2010–2011 http://www.chp.edu/CHP/Home
60. CFCC: Western Psychiatric Institute and Clinic Largest psychiatric facility in Western PA Serves over 25,000 patients and families/yr Full continuum of services including 24 hour psychiatric emergency room Residency training site for Triple Board Program and Family Practice/Psychiatry Program http://www.upmc.com/HospitalsFacilities/Hospitals/wpic/Pages/default.aspx
61. CFCC Partnership Mission Statement “ …a collaborative effort between pediatricians, licensed clinical social workers, psychologists and psychiatrists to provide timely access to high-quality, empirically-supported behavioral health assessments, behavioral interventions, and psychiatric interventions to children and families in an integrated model of care provided within the pediatric primary care office.”
62. CFCC: 2007 Pilot Project BH specialist in 1 CCP office 2 days/week (therapist, child & adolescent psychiatrist) Referral indications and exclusions identified Clinical treatment protocol outlined Training sessions for all staff Centralized registration and billing Electronic Medical Records
81. Family supportReferral to Behavioral Health Therapist for assessment and possible treatment Pediatrician refers to Emergency Dept. or appropriate community agency Managed by the Pediatrician Non-behavioral concerns are not referred to behavioral provider: Custody Issues CYF/child welfare issues Learning/school evals Financial/housing, etc. If no symptoms resolution or specialized care required (bipolar disorder, psychosis, etc.) Referral to child psychiatrist Pediatrician refers to appropriate community agency Therapists/psychologist collaborate with psychiatrist and pediatrician G.Crum/A.Schlesinger 5-13-08
82. CFCC: Beyond the Pilot 2 Child and Adolescent Psychiatrists 2 Triple Board trained Physicians Therapists at 14 different locations Non CCP patients seen at central location (Pine Center, Wexford Office)
83. CFCC: Beyond the Pilot, Cont. > 1500 patients seen since Aug 2008 Ave approx 600 visits/month Approx 10% no show rate 80% diagnoses = anxiety, depression, or ADHD Comorbidity Depressive & Anxiety d/o Anxiety d/o & ADHD
84. CFCC: Strategies for Success Buy in by all invested parties Monthly meetings Provide staff with appropriate tools/support Centralized billing
85. Communication is the key Office Managers Nurses Operations Scheduling Staff Front desk Triage Staff Families
87. Policy Implications 2010: Patient Protection and Affordable Care Act Demonstration Projects Medicaid Medical Home Pilot: Sec 2703 Medicaid Accountable Care Organization Pilot Program: Sec 2706 Co-location of Primary and Specialty Care in Community-Based Behavioral Health: Sec 5604
88. Policy Implications, Cont. Improve reimbursement rates Improve incentives for screening and prevention Recommend collaboration among Department of Health and Human Services agencies (HRSA, SAMHSA, etc)
89. Thank You! Kenneth Thompson, MD Abigail Schlesinger, MD Norman Cohen, MD Roberto Ortiz-Aguayo, MD Art Kovel, MD Carl Bell, MD Kristin Dalope, MD Lynn Malec, MD Sheree Shafer Gretchen Crum WPIC Triple Board Program APA Public Psychiatry Fellowship
90. References AACAP Committee on Health Care Access and Economics, AAP Task Force on Mental Health. Improving Mental Health Services in Primary Care. Pediatrics Volume 123, Number 4: 1248-1251, April 2009 American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Osteopathic Association. Joint Principles of the Patient-Centered Medical Home. Elk Grove Village, IL: American Academy of Pediatrics; 2007. Available at: http://www.medicalhomeinfo.org/Joint%20Statement.pdf. Capko J., Practice Points: Home Sweet Medical Home. Repertoire, January 2011;19: Collins C, Hewson DL, et al. “Evolving Models of behavioral Health Integration in Primary Care. Milbank Memorial Fund. May 2010 Doherty, W. The Why’s and Levels of Collaborative Family Health Care. Family Systems Medicine. 1995;13(3–4):275–81. Goinik A, et al. Medical Homes for Children with Autism: A Physician Survey. Pediatrics Volume 123, Number 3: 966-971, March 2009 Horowitz L.M, Ballard ED, Pao M. Suicide screening in schools, primary care and emergency departments. Current Opinion in Pediatrics. 2009; 21 (5): 620-627 Holt, W. “The Massachusetts Child Psychiatry Access Project: Supporting Mental Health Treatment in Primary Care, A Case Study by the Commonwealth Fund,” March 2010. Lake, Raymond. How academic psychiatry can better prepare students for their future patients. Part I: the failure to recognize depression and risk for suicide in primary care; problem identification, responsibility, and solutions. Behav Med. 2008 Fall;34(3):95-100. Martin P., Griffin M., Krasnik C., “All in the Family: The Benefits and Challenges of Collaborative Health Care Models.” APA 62nd Institute on Psychiatric Services. October 15, 2010 Merikangas KR, He J, Burstein M, Swanson SA, Avenevoli S, Cui L, Benjet C, Georgiades K, Swendsen J. Lifetime Prevalence of Mental Disorders in U.S. Adolescents: Results from the National Comorbidity Survey Replication-adolescent Supplement (NCS-A). JAACAP . 2010; 49 (10): 980-989
91. References, Cont. O'Connell ME, Boat T, Warner KE. Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities. The National Academies Press 2009. Policy Statement- The Future of Pediatrics: Mental Health Competencies for Pediatric Primary Care. Committee on Psychosocial Aspects of Child and Family Health and Task Force on Mental Health. Pediatrics Volume 124, Number 1:410-417,July 2009 Sarvet B., Gold J., Bostic, J.Q., et al., “Improving Access to Mental Health Care for Children: The Massachusetts Child Psychiatry Access Project,” Pediatrics, December2010; 126;1191-1200 U.S. Department of Health and Human Services. Mental Health: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health, 199 The President’s New Freedom Commission on Mental Health. Achieving the Promise: Transforming Mental Health Care in America. July 2003 http://www.ahrq.gov/ http://www.mcpap.com/index.asp http://www.nacronline.com/recovery-issues/dealing-with-your-dark-side-part-4 http://www.nih.gov http://samhsa.gov www.aap.org www.aacap.org www.psych.org www.thenationalcouncil.org
92. Promoting Improved Integration: An Examination of Collaborative Health Care ModelsPresented by the APA Council on Advocacy and Government Relationsat the 2011 Annual Meeting of the American Psychiatric AssociationMay 17, 2011 | Honolulu, HawaiiPaying for Integration Margaret Balfour, MD, PhD APA/BMS Public Psychiatry Fellow Public Psychiatry/T32 Postdoctoral Research Fellow University of Texas Southwestern Medical Center at Dallas
93. Integration can be… How services are organized, infrastructure, etc. Payment mechanisms and policies What the consumer experiences
94. Foundations of clinical integration Clinical integration is the ultimate goal. Financial and structural integration don’t automatically result in clinical integration. But it’s difficult to have clinical integration without financing and infrastructure that support collaboration.
95. Many barriers to financial integration http://www.thenationalcouncil.org/galleries/resources-services%20files/BHCoverage_onSameDay_byState_9_14.BMP
96. Lack of Medicaid reimbursement for: Same-day visits Undermines the concept of “warm-handoffs” and co-location Care management and provider communication Which is the centerpiece of collaborative models PCPs coding primary mental health diagnoses Screening and prevention SAMHSA. Reimbursement of Mental Health Services in Primary Care Settings. 2008. http://download.ncadi.samhsa.gov/ken/pdf/SMA08-4324/SMA08-4324.pdf
97. Health plan barriers Carve-outs: lack of reimbursement for PCPs outside the health plan no financial incentive for coordination of care with physicians in other panels Medical cost savings not on the radar No reimbursement for consultation, team meetings or phone calls Even if one health plan has a perfect reimbursement model, most practices have patients on many different plans AHRQ. Integration of Mental Health/Substance Abuse and Primary Care, 2008. http://www.ahrq.gov/downloads/pub/evidence/pdf/mhsapc/mhsapc.pdf
98. Looking to the literature Many programs are grant funded, and extra FTEs and services may not be sustainable outside the pilot/clinical trials environment Studies usually don’t go into detail about funding mechanisms Many studies compare different clinical and structural models, but none directly compare financial models Mostly have to rely on case studies at this point But groups are starting to study “real-world” implementation/financing issues. AHRQ. Integration of Mental Health/Substance Abuse and Primary Care, 2008. http://www.ahrq.gov/downloads/pub/evidence/pdf/mhsapc/mhsapc.pdf
99. RWJF Depression in Primary Care Program Goal is to identify and implement economic and organizational strategies that will sustain care improvements. Identified seven reimbursement models for care management Differ in where the care managers are based and how they’re funded. J. Bachman et al. Funding mechanisms for depression care management: opportunities and challenges. General Hospital Psychiatry 28 (2006) 278–288
100. Care management funding models Practice-based care management on a fee-for service basis Care managers are employees of the practice and located on-site Revenue flows from insurer to practice based on billing Depends on insurer/state policies and coverage Requires knowledge of covered CPT and HBAI codes J. Bachman et al. Funding mechanisms for depression care management: opportunities and challenges. General Hospital Psychiatry 28 (2006) 278–288
101. Care management funding models Practice-based care managers under contract to health plans Health plans contract with practices to provide CM to targeted plan members CMs can be employees of either the practice, the health plan, or a 3rd party entity Revenue for their services based on historical estimates of service costs and numbers served and paid in yearly or monthly retrospective payments J. Bachman et al. Funding mechanisms for depression care management: opportunities and challenges. General Hospital Psychiatry 28 (2006) 278–288
102. Care management funding models Global capitation Fully capitated HMOs have the flexibility to allocate resources They may choose to fund CMs internally Example: Kaiser Permanente Care Management Institute: www.kpcmi.org J. Bachman et al. Funding mechanisms for depression care management: opportunities and challenges. General Hospital Psychiatry 28 (2006) 278–288
103. Care management funding models Pay for Performance (P4P) Health plans offer financial incentives for meeting pre-defined performance improvement targets Revenue is re-invested to support care managers and other quality improvement initiatives J. Bachman et al. Funding mechanisms for depression care management: opportunities and challenges. General Hospital Psychiatry 28 (2006) 278–288
104. Care management funding models Health-plan based care management Care managers are employees of the health plan Provide services in the form of utilization review and care coordination with patients, behavioral health providers, PCP. Usually have little face-to-face contact with the patients Funded through administrative overhead paid to the health plan Works best when health plan is in close geographical proximity to providers so relationships can be developed. J. Bachman et al. Funding mechanisms for depression care management: opportunities and challenges. General Hospital Psychiatry 28 (2006) 278–288
105. Care management funding models Third-party based care management under contract to health plans Health plans subcontract for CM services with disease management organizations, managed behavioral healthcare organizations, or CMHCs Payments typically capitated with a PMPM payment based on historical estimates of costs and numbers served J. Bachman et al. Funding mechanisms for depression care management: opportunities and challenges. General Hospital Psychiatry 28 (2006) 278–288
106. Care management funding models Hybrid models Combinations of all the above For example: CMHC care managers placed in primary care, partly funded via fee-for-service billing, and partly through health plan contracts J. Bachman et al. Funding mechanisms for depression care management: opportunities and challenges. General Hospital Psychiatry 28 (2006) 278–288
107. Coding tips: Diagnosis and CPT E&M Study of depression claims in primary care settings to evaluate reasons for denials Found that most were coding errors not necessarily specific to MH policy issues http://www.machc.org/
108. Coding tips: HBAI codes Health and Behavior Assessment/Intervention Codes for non-physicians in primary health settings American Psychological Association online tool http://flash1r.apa.org/apapractice/hbcodes/player.html
110. Other tools To assess funding environment Kaiser Commission Report on Medicaid and the Uninsured State by state description of covered services and reimbursement methods, available Level II HCPCS codes, etc. http://www.kff.org/medicaid/benefits/service.jsp?nt=on&so=0&tg=0&yr=2&cat=7&sv=40 NCCBH Environmental Assessment Tool State Level Policy and Financing Questionnaire to assess whether state polices will promote or act as a barrier towards integration http://www.thenationalcouncil.org/galleries/business-practice%20files/PC-BH%20Environment-State%20Policy.pdf Lots of other resources: SAMHSA-HRSA Center for Integrated Solutions http://www.thenationalcouncil.org/cs/center_for_integrated_health_solutions
111. The future? PPACA creates new Center for Medicare and Medicaid Innovation (CMI) Funds payment reform pilots that promote payment for value rather than payment for volume. Case-rate: bundled payments for an individual for an episode of care Global payments: bundled payments for an individual for a period of time Removes barriers, creates more flexibility, incentives for prevention and integration models Dale Jarvis, The Business Case for Bidirectional Integrated Care. 2010. http://www.thenationalcouncil.org/galleries/policy-file/CiMH%20Business%20Case%20for%20Integration%206-30-2010%20Final.pdf
112. Further in the future? Move away from our “sick care” system Towards Patient-Centered Medical Homes supported by Accountable Care Organizations (The following slides were gratuitously stolen (with permission) from a presentation at the recent NCCBH conference by Dale Jarvis and Andy Keller.)
119. EquitableACO delivery organizations that facilitate the work of patient- centered teams The Fix: There is an emerging consensus about how to fix the health care system. The Institute of Medicine describes the fix with the following diagram. In order to achieve desired outcomes, the delivery system must organize itself into high performing patient-centered teams supported by health care organizations that facilitate this work. This requires: Person-Centered Healthcare Homes Supported by Accountable Care Organizations. These organizations, in turn, must be supported by the payment and regulatory system.
121. And Organizing the Safety Net Payors Washington State’s fledgling two-part effort: A Regional Health Authority to organize the payors to create a supportive payment and regulatory system That will, in turn, support organizing the delivery system into accountable systems of care
122. KEY IDEA: Get the payors working together in the same way we’re expecting the providers to work together
123. Questions? Viewable slideshow: http://www.slideshare.net/collaborativehealthcaremodels/ Downloadable PDF: http://sites.google.com/site/collaborativehealthcaremodels/ Contact Information Peter Martin: psmartin@gmail.com John Lusins: drjlusins@gmail.com Marilyn Griffin: griffinm3@upmc.edu Margaret Balfour: margaret.balfour@gmail.com
Editor's Notes
Traditional collaborative/integration models: really focused on just the main providers, may not really incorporate the pt needs, but at least is a good starting to point to think of where to place those who deliver the services
COORDINATED • Routine screening for behavioral health problems conducted in primary care setting• Referral relationship between primary care and behavioral health settings • Routine exchange of information between both treatment settings to bridge cultural differences • Primary care provider to deliver behavioral health interventions using brief algorithms• Connections made between the patient and resources in the community
CO- LOCATED• Medical services and behavioral health services located in the same facility • Referral process for medical cases to be seen by behavioral specialists• Enhanced informal communication between the primary care provider and the behavioral health provider due to proximity• Consultation between the behavioral health and medical providers to increase the skills of both groups• Increase in the level and quality of behavioral health services offered• Significant reduction of “no-shows” for behavioral health treatmentShared care:1) Washtenaw Community Health Organization (Michigan): The Washtenaw Community Health Organization is a partnership between the county public mental health system and the University of Michigan Health System. The partnership allows for pooling of funds across systems and shared risk. Mental health clinicians from the community mental health center are out-stationed to primary care practices to provide direct treatment. A psychiatrist provides consultation to local public health clinics. The project has added a reverse co-location initiative (see discussion of Practice Model 5) by having a nurse practitioner visit community mental health clinics to provide primary care as well as to coordinate with the patient’s physician if there is one.2) VHA: One model uses a nurse care manager to provide telephone monitoring to individuals with depression and referral to specialty care when needed. The other model uses a software-based assessment to determine three interventions: watchful waiting, treatment by the primary physician, and referral to specialty care.
CO- LOCATED• Medical services and behavioral health services located in the same facility • Referral process for medical cases to be seen by behavioral specialists• Enhanced informal communication between the primary care provider and the behavioral health provider due to proximity• Consultation between the behavioral health and medical providers to increase the skills of both groups• Increase in the level and quality of behavioral health services offered• Significant reduction of “no-shows” for behavioral health treatmentShared care in reverse:1)Health and Education Services (HES) (Massachussets): a nonprofit, fullservice mental health organization in the North Shorearea. HES is focused on improving the physical health care of its Latino population. A Spanish-speaking nurse practitioner, who has expertise in both primary care and psychiatry, regularly visits three clinics. The nurse is available on a walkin basis to see patients with a range of medical issues.2) Horizon Health Services (NY): Horizon Health Services is a provider of comprehensive substance dependence and mental health services in Buffalo. Three of Horizon’s sites have medical units, where patients are offered an appointment if they do not have a primary care physician. The medical staff includes a family physician, registered nurse, nurse practitioner, LPNs, and HIV counselors.
INTEGRATED• Medical services and behavioral health services located either in the same facility or in separate locations• One treatment plan with behavioral and medical elements• Typically, a team working together to deliver care, using a prearranged protocol• Teams composed of a physician and one or more of the following:physician’s assistant, nurse practitioner, nurse, case manager, family advocate, behavioral health therapist • Use of a database to track the care of patients who are screened into behavioral health servicesPrimary care psychiatrist:1) MIPS clinic (NY): Clinic located at Strong Ties in Rochester for those with SPMITypically not much focus on primary care psychiatrist – few providers, and still have multiple difficulties, including boundaries (“we don’t hug in psych”)
Those with low to moderate severity of mental health disorders but a higher level of medical co-morbidity would be best benefit from an integrated approach where mental health is incorporated into a primary care clinic
Personal physician- Each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care Physician directed medical practice- The personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients Whole person orientationThe personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals. Includes care for all stages of life; acute care; chronic care; preventive services; and end of life careCare is coordinated and/or integratedAcross all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (e.g., family, public and private community-based services) Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner Enhanced access- Care is available through systems such as open scheduling, expanded hours and new options for communication between patients, their personal physician, and practice staffQuality and safety Practices advocate for their patients to support the attainment of optimal, patient-centered outcomes that are defined by a care planning process driven by a compassionate, robust partnership between physicians, patients, and the patient’s family Evidence-based medicine and clinical decision-support tools guide decision making Physicians in the practice accept accountability for continuous quality improvement through voluntary engagement in performance measurement and improvement Patients actively participate in decision-making and feedback is sought to ensure patients’ expectations are being met Information technology is utilized appropriately to support optimal patient care, performance measurement, patient education, and enhanced communication Practices go through a voluntary recognition process by an appropriate non-governmental entity to demonstrate that they have the capabilities to provide patient centered services consistent with the medical home model Patients and families participate in quality improvement activities at the practice levelPayment: recognizes the added value provided to patients who have a PC-MH and based on the following framework Reflect the value of physician and non-physician staff patient-centered care management work that falls outside of the face-to-face visit Pay for services associated with coordination of care both within a given practice and between consultants, ancillary providers, and community resources Support adoption and use of health information technology for quality improvement Support provision of enhanced communication access such as secure e-mail and telephone consultation Recognize the value of physician work associated with remote monitoring of clinical data using technology Allow for separate fee-for-service payments for face-to-face visits. Payments for care management services that fall outside of the face-to-face visit, as described above, should not result in a reduction in the payments for face-to-face visits Recognize case mix differences in the patient population being treated within the practice Allow physicians to share in savings from reduced hospitalizations associated with physician-guided care management in the office setting Allow for additional payments for achieving measurable and continuous quality improvements **Medicaid: those with this insurance typically have more instability, more likely to utilize ED services; majority of those on this have multiple chronic conditions with wide psychosocial needs **Funding for IT will help push PCMH
CO- LOCATED• Medical services and behavioral health services located in the same facility • Referral process for medical cases to be seen by behavioral specialists• Enhanced informal communication between the primary care provider and the behavioral health provider due to proximity• Consultation between the behavioral health and medical providers to increase the skills of both groups• Increase in the level and quality of behavioral health services offered• Significant reduction of “no-shows” for behavioral health treatment
High BH-low physical health complexity/risk, served in a specialty BH system that coordinates with the PCP.
This afternoon I will briefly discuss the current problems we face within the field of CAP, some creative solutions, and 2 successful models of integration. I will conclude by discussing some policy changes that have occurred to promote the development of integrative models of care.
In 2001, Dr. David Satcher declared a state of crisis in the mental health of children and adolescents
The statistics are alarming. Almost one in five children have a diagnosable mental health disorder at any given time. Up to 1/2 of all lifetime cases of mental illness begins by age 14. And yes, psychosocial and mental health concerns are often mentioned during primary care appointments, but there are still approx 80% of kids with psychopathology who are not identified or treated. The consequences of untreated mental health disorders have a domino effect. It is known that children and adolescents that are untreated have higher school absence rates, lower school performance, impaired relationships, higher rates of STDs, pregnancy, and substance abuse, limited to no employment opportunities, and poverty in adulthood.
Mental illness, whether untreated or treated, account for considerable costs to multiple systems of care, an estimate of over $200 billion annually.This slide, although rather busy, is another take on the domino effect. Anindividual’s health problems, in turn, may lead to adverse consequences for others. In addition, health problems typically lead to increased costs secondary to reduced productivity and earnings and the increased use of social services such as child welfare and juvenile justice. As cliché as it may sound, the children are our future and they deserve a place that not only identifies and treats pathology, but promotes physical and mental well being.
Such interventions can be integrated with routine health care and wellness promotion, as well as in schools, within families, and in the community. This would require the collaborative efforts of a multidisciplinary team including pediatricians, psychiatrists, educators and community based agencies to build strong children.
To meet the needs of the children, there has to be a sufficient number of providers. And we all are aware of the workforce shortage. A study commissioned by the AACAP in 2003 found there was, on average, only one child psychiatrist for every 15,000 youth under 18. The data shows that Pennsylvania is one of the few states with a higher number of CAPs, however the need is still abundant. The U.S. Bureau of Health Professions project that there will be 8,300 CAPs in 2020 but they are also projecting the need of 12,600 CAPs to provide services
These numbers highlight the need to develop prevention training standards and training programs across disciplines including health, education, and social work. There are available training programs on mental health topics for primary care resident physicians, continuing medical education courses for established primary care providers, and continuous quality improvement (CQI) initiatives for entire health care systems. However, there are some studies that show these education and training approaches have not been shown to have consistent beneficial effects on either provider behaviors or patient-level outcomes, especially long-term.
With the current NFL lockout , increasing numbers of children and adolescents in need of mental health services and the shortage of providers, there is a need for some creative solutions…. Thank goodness for hockey and basketball!
The concept of the medical home was first introduced by the American Academy of Pediatrics
The interpretation of the medical home has transformed over the years and in 2007 the collaborative efforts of the American Academy of Family Physicians, American Academy of Pediatrics,American College of Physicians, and American Osteopathic Association outlined 7 principals of the Patient-Centered Medical Home.
Personal physician: Each patient is to have an ongoing relationship with a personal physician trained to provide 1st contact, continuous and comprehensive care.Physician directed medical practice:The personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients Whole person orientation: The personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals. Care is coordinated across all elements of the complex health care system and the patient’s community.Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need in a culturally and linguistically appropriate manner Enhanced access: Care is available through systems such as open scheduling, expanded hours and new options for communication between patients, their personal physician, and practice staff Quality and safety: Practices advocate for their patients to support the attainment of optimal, patient-centered outcomes. Evidence-based medicine and clinical decision-support tools guide decision making. Information technology is utilized appropriately to support optimal patient care, performance measurement, patient education, and enhanced communication Payment should recognize the added value provided to patients who have a PC-MH and should reflect the value of physician and non-physician staff care management work that falls outside of the face-to-face visit. Payment should also support provision of enhanced communication access such as secure e-mail and telephone consultation and recognize the value of physician work associated with remote monitoring of clinical data using technology.
The medical home model provides children and families the opportunity to engage in mental health services within a familiar environment anddecreasing the stigma attached to seeking mental health treatment. There are several other benefits of this model, especially improving access to care.
While the concept of a medical home is not specifically an integrated behavioral health model, it clearly encompasses the philosophy of integration. This model has the potential to shift costs from acute care to prevention, chronic care management and recovery
Bridging the patient –centered medical home with integrated care is an innovative approach that facilitates partnerships between individuals and their healthcare providers
Collaborative care and integrated care are the two terms most often used to describe the interface of primary care and behavioral health care. They are often used interchangeably, but the terms are not used consistently in the field. Biopsychosocial model acknowledges that biological, psychological, and social factors all play a significant role in human functioning in the context of disease. This model is endorsed by most medical professionals yet seldom practiced. However, it is the theory at the root of collaborative and integrated care and is universally embraced as a “best practice.”
many integrated programs around the country have combined elements of two or more of the models previously discussed. These blended programs are becoming more common because programs are often designed for a particular set of local or statewide circumstances, such as target population, provider and service capacity, funding issues, and regulatory restrictions.
The Child and Family Counseling Center is a program here in Pittsburgh based on the medical home model that was developed to provide an unmet need for behavioral health services within local pediatric offices.
There was a need to provide evaluation and treatment for common mood, anxiety, and behavioral disorders
A collaborative partnership was developed using consultative and co-location models of care between three systems, CCP, CHP and WPIC
CCP is a collective group of over 100 pediatricians and several mid level providers who deliver primary care services out of 28 offices which span 8 counties within the greater Pittsburgh area
CHP is a large level 1 trauma center serving Western PA. CHP was named one of 8 of America’s Best Children’s Hospitals per US News and World Report.
And WPIC, is one of the largest psychiatric facilities in Western PA serving 25 thousand patients and families a year. It is the site of two combined residency programs, TB and FP/Psych
To paraphrase, the initialmission of this collaboration was to provide access to quality, evidenced based behavioral health assessments, interventions and treatments in an integrated model within the pediatric primary care setting. Akey to successful implementation of such care is bidirectional communication between PCP and BH providers
In 2007 the CFCC pilot project was launched. Using a consultative and co-location model, BH specialists were placed in the primary care office to provide evaluation, assessment and treatment of patients referred by their pediatrician. Referral guidelines and treatment protocols were established and adhered to by all providers. Training sessions were provided and consisted of topics ranging from the general nuts and bolts of the program to management of common parental BH questions via phone triage. The use of EMR helped to streamline registration, authorizations, billing and communication.
I know this is a busy slide, but I wanted to give you an idea of how the CFCC system works. Who and where the care is provided is determined by the severity of symptoms and degree of impairment. Mild symptoms and impairment of various disorders are managed by the pediatrician \\during routine office visits. Moderate to severe symptoms and impairment warrants a referral to a behavioral health therapist for assessment, diagnosis and appropriate treatment. Behavioral health therapist will then refer to the child psychiatrist if medication management is required. Lastly, the pediatrician will refer pts with immediate safety issues to the psychiatric ED or appropriate community agency.
The pilot was a success and the Child and Family Counseling Center now has 4 child and adolescent psychiatrist providers, 2 of which are triple board trained. Therapists are located at 14 different CCP locations. The center will also see patients who are referred from non Children’s Community Pediatric offices at the central office location in Wexford
Since Aug of 2008, over 1500 patients have been seen with an average of approx 600 behavioral health visits/month and only a 10% no show rate. As with the national trends, 80% of the diagnoses seen are anxiety, depression or ADHD. And comorbidity does exist.
In speaking with the pioneers of the program, the strategies for the programs success included buy in by all parties. Everyone must see the value of integration including providers, staff, and most importantly patients and their families. BH manager attended monthly primary care meetings and CAP facilitate BH training sessions for pediatric providers and staff. There is one expert responsible for completing eligibility requirements and billing for all participating practices. For example, once a patient encounter is closed, charges are dropped into an electronic work queue that is processed by the expert.
The underlying theme for the success of the program is communication… not included in this slide but important role players are other systems of care such as education, the child welfare system, and juvenile justice to name a few.
Some of the barriers to developing collaborative models are the same as the barriers to mental health care in general… poor access, shortage of providers, stigma, and cultural differences with the traditional delivery of medicine in separate silos and last but certainly not least, funding.
The Patient Protection and Affordable Care Act has set aside millions of dollars to assist states in planning and implementing Medicaid medical home projects. The Medicaid accountable care organization pilot program establishes a project that will allow qualified pediatric providers to receive recognition and payments under Medicaid as accountable care organizations. In addition, $50 million in grants will be authorized for coordinated and integrated services through the co-location of primary and specialty care in community-based mental and behavioral health settings. According to the patient centered- primary care collaborative, some 44 states and the District of Columbia have passed more than 330 laws relating to the medical home
There is a need for continuous advocacy efforts to improve reimbursement rates, and incentives for mental health screenings and prevention during primary care well child checks are paramount.