Integrated Care: Where Clinical Need Intersects Sustainability

1. Session #G2 October 5, 2012 Integrated Care: Where Clinical Need Intersects Sustainability Collaborative Family Healthcare Association 14th Annual Conference October 4-6, 2012 Austin, Texas U.S.A.

2. Integrated CareWhere Clinical Need IntersectsSustainability Behaviorally Enhanced Health Care Home Kimberly A. Arlinghaus, M.D. Medical Director, Behavioral Health Lone Star Circle of Care Department of Psychiatry and Behavioral Health 512-686-0207 ext. 10375 karlinghaus@lscctx.org Greg Jensen, LCSW, ACSW Vice President for Behavioral Health Lone Star Circle of Care Department of Psychiatry and Behavioral Health 512-686-0207 ext. 10135 gjensen@lscctx.org

3. Brian … 17 y/o HM • PTSD, Bipolar d/o, Polysub abuse, ADHD • 4 SAs 12-16 y/o • Multiple psych hosp, BBT, PP therapists, primary care Carousel Pediatrics • Psych meds by Carousel • HTN, reflux, “passing out” w/hx of head injury

4. Psychiatrist-Therapist Collaboration • BH intake by therapist • Psychiatric evaluation—added hx psychosis, TBI, and changed BD to MDD; changed medications • Ongoing med management, psychotherapy, and encouragement to enroll in LSCC primary care

5. Psychiatrist-Therapist-PCP Collaboration • LSCC PCP visit • Facilitated neurology work-up for TBI and question of seizures • Obtained additional medical records • Assisted with checking drug screens and monitoring suicidality

6. Network Collaboration • Seton ER • Consultation with ER physicians • Hospitalization • IOP, 12-step • LSCC for therapy, medication management, primary care

7. The Bottom Line…Shared Care is Best Care Right thing to do for the patient Adds value to the community Sustainable and scalable

8. Goals For Today • Establish the vision and mission concepts necessary to create organizational commitment to integrated care • Define governance, operational, financial and clinical issues to implement a behaviorally enhanced community health center • Discuss critical sustainability success factors and challenges

9. Vision Every Central Texan who needs access to psychiatry and psychotherapy will have access to a fully integrated, behaviorally enhanced, healthcare home

10. LSCC Behavioral Health: Mission • Provide behaviorally-enhanced healthcare services to patients who have LSCC as their medical home • Provide access to BH services in collaboration with community partners who have aligned and complementarygoals

11. LSCC Clinics LSCC services offered in each city: • Austin • Family Medicine • Behavioral Health • Belton • Pediatrics • Cedar Park • Pediatrics • Georgetown • Family Medicine • Senior Health • Pediatrics • Behavioral Health • Pharmacy • Dental • Harker Heights • Pediatrics • Behavioral Health (child & adolescent) • Hutto • Pediatrics • Killeen • Pediatrics • Round Rock • Family Medicine • OB/GYN • Senior Health • Pediatrics (also Adolescent) • Behavioral Health • Pharmacy • Taylor • Family Medicine • Temple • Family Medicine Lone Star Circle of Care / Locations

12. Locations of LSCC Dedicated BH Clinics

13. “The Usual Way” PsychiatryOutsourced Mental Health Stigma Medicine

14. “The Lone Star Circle of Care Way” Behavioral Health Providers (Psychiatrists and Counselors/Therapists) are members of LSCC medical team thereby leveraging ALL Integrated Delivery System benefits

15. Integrated Care: Why Do It? Up to 70% of patients presenting for primary care have some type of behavioral health (BH) problem which impacts diagnosis and treatment Patients are more likely to receive BH treatment if they are treated via an integrated model Treatment of BH problems enhances medical outcomes and quality of life Integrated care optimizes efficiency of health care delivery

16. Depression and Diabetes • 95% of diabetes management is conducted by the patient • If the patient is depressed… • Poorer outcomes • Increased risk of complications • < glucose monitoring • < adherence to diet, exercise, and medication regimens

17. Potential Systemic Effects of the “Depressed” Brain • Sticky platelets • Decreased heart rate variability (HRV) • Increased C-reactive protein • Increased cortisol

18. Systemic Effects of Cortisol • Redistribution of body fat • High sympathetic tone • Elevated noradrenaline • Increased HR • Reduced HRV • Decreased insulin sensitivity • Decreased bone absorption of calcium

19. Depression Worsens Outcome of Heart Disease • Depression worsens morbidity and mortality after myocardial infarction1,2 • Depression increases morbidity and mortality in patients with CHF3,4 1. Frasure-Smith N, et al. JAMA. 1993;270:1819-1825. 2. Penninx BW, et al. Arch Gen Psychiatry. 2001;58:221-227. 3. Jiang W, et al. Arch Intern Med. 2001;161:1849-1856. 4. Vaccarino V, et al. J Am Coll Cardiol. 2001;38:199-205.

20. Behavioral Cardiology (Pickering et al. 2003) • The causes of heart disease lie not so much in the heart itself, but in the brain, or more specifically, the mind. • The mind affects the heart via: • Our lifestyles • Effects of psychosocial stresses and how we cope with them

21. Integrated Care Outcomes Research Better Outcomes/Improved Functioning: Independent Three-year Process and Outcome Evaluation (Dr. Toni Watt, Texas State University. Commissioned by St. David’s Community Health Foundation, 2008) Statistically significant decrease in depression symptoms (32%) that remained constant over two, three and six month period Self-report measures showed patient’s physical health, daily living activities performance, ability to socialize improved significantly Treating BH illnesses does not cost the overall health system more money. While there was an initial increase in costs, from 6-21 months post treatment, the costs remained stable

22. Integrated Care: Solution An Institute of Medicine report in 2005 concluded that the only way to achieve true quality (and equality) in the health care system is to integrate primary care with mental health care and substance abuse services. (Institute of Medicine, “Improving the Quality of Health Care for Mental and Substance-Use Conditions: Quality Chasm Series”, November 1, 2005.)

23. Integrated Care: What Differentiates LSCC’s Model • BH and medical providers employed by LSCC • BH and medical providers on the same HER • LSCC treats ALL psychiatric groups • BH records fully open to the medical providers • Medical providers have immediate access to psychiatrists • BH specialists embedded into the medical clinics • Single governance structure that develops the integrated services • Active mental health screening in medical clinics • Psychiatrists actively treating patients vs. consultant

24. Governance: Behaviorally Enhanced Healthcare Integration Council • Provide guidance to and oversee integration implementation • Define and monitor outcome measures • Set professional practice standards such as defining and utilizing screening tools, establishing interdisciplinary care conferences, etc. • Establish reimbursement guidelines • Provide recommendations to LSCC Senior Leadership pertaining to the ongoing practice issues, resources and/or enterprise-wide impact of integration

25. Addressing PCP Challenges: Time and Access • Embedding behavioral health specialists • Provide “real time” consultation to medical staff • Conduct crisis intervention for patients in the clinic • Facilitate and expedite access to psychiatric services • Provide brief therapy/counseling services to patients • Coordinate care with the patient’s PCP • Assist with efficient patient flow • Real time PCP consultation with child and adult psychiatrists • Telepsychiatry

26. The LSCC Integrated BH Model: Screening Medical patients for mental health concerns • TeenScreen for 11-17 year olds • PHQ 2 for depression • CAGE for substance use • Vanderbilt for ADHD • AD8 for cognitive decline in older adults • Edinburgh 3 for post partum depression • MCHAT for autism Behavioral health patients for medical concerns • Primary care service provider (medical home) • Hypertension • Obesity • Diabetes • Co-occurring substance use disorders • Tobacco product use • Pain

27. LSCC’s Integrated Care Model Providing holistic care by diagnosing and treating physical AND mental conditions … together BH screening in medical clinics EmbeddingBH providers using open access Providing PCPs direct access to psychiatrists Interdisciplinary collaboration Electronic health record

28. Easy Access to Clinical Information: EHR

29. Increasing Access 2006-2012 1 to 17 prescribers 0 to 31 therapists

30. Behavioral Health Visits By Patient’s Residence

31. Behavioral Health as % of Total LSCC Visits

32. % of Behavioral Health Patients with LSCC Medical Home

33. Integrated Behavioral Health Sustainability and Scalability • Provider Mix • Psychiatrists AND therapists with same employer as medical providers • Payer Mix • Leverage FQHC to increase access to mission patients • Productivity • Goals by provider type

34. Behavioral Health – Utilization (January 2012-August 2012)

35. Challenges: No Shows and Utilization • No Show Policy • Confirmation Calls • Reverse Confirmation Calls • Therapist-Based Intakes • Same Day Call In List • Intakes at Same Time and Overbook

36. Integrated Behavioral Health Outcomes & Scalable Results • Quality Metrics • Symptom reduction • Functional improvement (future) • Access • Assess safety at each visit • Operational Metrics • Volume • Productivity • Satisfaction Metrics • Patient satisfaction data

37. Integrating Education and Clinical Service BH Training Partnerships Seton/UT Southwestern Psychiatry Residents Texas A&M Medical Students UT School of Social Work UT School of Educational Psychology UT College of Nursing

38. Psychiatry and Behavioral Health – Community Partners Texas A&M Health Science Center Seton Family of Hospitals University of Texas Southwestern /Seton Residency Program St. David’s Foundation Scott and White Bluebonnet Trials – Williamson County MH/MR STARRY Texas Baptist Children's Home Caring Family Networks Arrow Child and Family Ministries Lighthouse Family Network Central Texas Children’s Home Texas Star Recovery Center Department of State Health Services Texas A&M School of Rural Public Health University of Texas School of Social Work Williamson County Mobile Outreach and Wilco MH Task Force Wilco and ATCIC Community Providers

39. New Initiatives in Behavioral Health

40. Austin Independent School District (AISD) Grant funded 6 month pilot at Crockett HS March-August 2012 Clinic operational and seeing students

41. Austin Independent School District (AISD) Goals Evaluate model Sustainability Replicate

42. Foundations Communities Local non-profit providing housing and support services for thousands of low-income families and individuals.

43. Foundations Communities Grant improves BH access • Psychiatry ½ day/wk. • Refer to therapy as needed Medical home provided through LSCC PCPs

44. Lifeworks Non-profit social service agency providing a continuum of services to youth and families transitioning from crisis to safety.

45. Lifeworks • St. David’s Foundation funds Lifework’s Shared Psychiatric Services (SPS) for short term psychiatric care • LSCC’s provides a medical and BH home for children and their parents transitioning from SPS

46. Family Drug Treatment Court/Parents in Recovery (FDTC/PIR) Families identified by judicial and Child Protective Services (CPS) due to mother’s substance abuse Reduce children in out-of-home placements and increase children reunited with families

47. Family Drug Treatment Court/Parents in Recovery (FDTC/PIR) Partnerships with Austin Recovery and FDTC/PIR Transition mothers and her infant/children into our medical and BH home

48. Joint Commission Accreditation A nationally-recognized “gold seal of approval” for health care providers Signifies that the safety and clinical qualify of care provided is exceptional Patient-Centered Medical Home (Level 3) recognition A recognition awarded by the National Committee on Quality Assurance Less than 0.5% of all primary care providers in the nation have this prestigious designation Awards and Recognition

50. Please complete and return your session evaluation form before you leave this session Please complete and return theevaluation form to the classroom monitor before leaving this session. Thank you!