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Integrated Care at The Providence Center 2014

Integrated Care at The Providence Center 2014. Presented by: Nelly Burdette, PsyD Director of Integrated Care The Providence Center. Background. Rhode Island’s largest community mental health organization with an annual budget of $42 million.

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Integrated Care at The Providence Center 2014

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  1. Integrated Care at The Providence Center 2014 Presented by: Nelly Burdette, PsyD Director of Integrated Care The Providence Center

  2. Background Rhode Island’s largest community mental health organization with an annual budget of $42 million. In 2013, we served 12,777 people with services provided statewide through 14 service locations in Providence, Burrillville, Cranston, Pawtucket, and Warwick, and 13 client residences in Providence. 5 main service divisions • Adult (SPMI and Health Home) • Child and Family • Wellness, Employment and Education • Residential Services • Crisis Care TPC’s main administrative offices and adult outpatient services on North Main Street in Providence.

  3. Gender 54% Male 46% Female Age 0-3: 1% 4-8: 5% 9-12: 5% 13-18: 12% 19-34: 21% 35-50: 29% 51-64: 22% 65+: 5% Race and Ethnicity White: 43% Latino: 21% Other/Unknown: 18% Black: 13% Native American: 3% Asian: 2% Primary Reimbursement Medicaid UBH: 19% Medicaid NHP: 17% Medicare: 14% Medicaid: 16% BCBS: 5% Uninsured: 4% Private: 2% TPC Demographics

  4. Most common across TPC (n=7501) Depression:26% Adjustment D/o: 11% Schizophrenia: 10% Mood Disorder: 9% ADHD: 8% Most common across Health Home (n=1878) Schizophrenia 33% Depression: 27% Bipolar: 13% Mood Disorder: 12% Adjustment D/o: 7% TPC Primary Diagnoses

  5. Goals of models Behavioral Health within Primary Care Setting Increase awareness of behavioral health care issues for both provider and patient Increase access to behavioral health screening and intervention Improve chronic disease management

  6. Behavioral health within PC • Part-time psychologist at largest PCHC site • Specially trained in integrated care within a primary care setting • Referrals comprised of a combination of traditional mental health and chronic disease lifestyle management • Model based on 30-minute triage/CBT interventions averaging 3-6 visits per patient, mostly triage and referral

  7. Behavioral health within PC Providence Community Health Centers at Prairie Avenue Collaboration Outpatient child and adult practice embedded within PCHC with bilingual therapist and bilingual child/adult psychiatrist New Health Home currently piloting

  8. Diagnostic Rankings Top three behavioral health diagnoses within FQHC (PCHC @ Prairie) Male & Female > 18 y/o • Depressive Disorder NOS • Recurrent Depression • Anxiety Disorder NOS Top three physical health diagnoses within embedded medical center of CMHC (PCHC @ NM) Male & Female > 18 y/o • Diabetes, Type 2 2. Hyperlipidemia 3. Hypertension

  9. Goals of models Primary Care within Mental Health Setting Improve morbidity and mortality of consumers with mental illness and addictions Decrease barriers to access to physical health care for consumers with behavioral health issues Improve health literacy for both providers and clients

  10. Primary care in behavioral health Providence Community Health Centers at North Main Street Opened June 2011 Physician, nurse, medical assistant & health centerdirector TPC-employed integrated care manager with a health literacy focus

  11. “We are partners in health.” “We treat complex patients who have complex problems, many of whom have not sought health care for a long time. I talk with my patients about about understanding what they have to do to get healthy and how I can support them.” -Dr. Tariq Malik, M.D., M.P.H., primary care physician at Providence Community Health Centers at North Main

  12. Personal trainers who are also trained case managers Individualized fitness and healthy lifestyle assessment performed by the health mentor for every participant Fitness plan, including eating, exercise, and health promotion Weekly individual meetings with a health mentor to participate in fitness activities from walking to gym attendance • Assistance with access to fitness resources • Opportunities for group exercise and healthy eating education

  13. Primary care in behavioral health SAMHSA funded PBHCI Grant • Awarded in 2010, 4 year grant • Emphasis placed on embedding medical nurse care managers in Home Health SPMI Teams • Education and triage related to management of chronic disease, greater access to primary care • PHQ9, AUDIT, Stanford Self-Efficacy, Self-Rated Abilities for Health Practices and SF-36 administered • Baseline, then every 3 months until one year completion, physical health measures including, BMI, Weight Loss, Blood Pressure, HbA1c, HDL, LDL and Triglycerides

  14. PBHCI Results Hospitalization Utilization Psych hospitalization and psych ER use significantly decreased Medical hospitalizations and medical ER visits increased. All types of hospitalizations showed a net decrease (156 days less net)

  15. Psych Hospitalization 428 days to 256 days = $122,120 savings National average $710 per day2 Psych ER 72 times to 33 times = $27,300 savings National average $700 per day1 SU Hospitalization 49 days to 24 days = $24,250 savings National average $970 per day2 TOTAL $173,670 savings for 350 individuals designated as SPMI Cost Savings (n=350)

  16. PBHCI Results Self-Efficacy (Stanford) Clients belief that they can communicate with physicians, manage disease in general, manage symptoms of disease, increase nutritional abilities, improve psychological well-being has significantly improved over one year with nurse care coordination.

  17. Physical Health Measures Statistically significant improvements over the course of one year in the below lab values Drawbacks: lab data difficult to obtain and as a result n quite small PBHCI Results

  18. Subjective Health (SF-36) Every aspect of health perceived to have statistically significantly improved over the course of the year, except bodily pain and health perception. PBHCI Results

  19. PBHCI Results If alcohol screening (AUDIT) initially at-risk (>8) AT BASELINE, there was a statistically significant decrease in risk after one year of nurse care management participation • Mean scores from 15.35 to 9.43 to 9.65. This is a significant decrease at p<.001. (n=40 to 23 to 20) If depression screening (PHQ-9) initially in the moderate range (>10) AT BASELINE (n=158), there was a statistically significant reduction over the course of one year. • Mean: 16.15 to 12.17 to 10.72 (p<.001)

  20. Weight change descriptives for BMI>30 at baseline: PBHCI Results: BMI • BMI (200 to 152 to 186): 38.5 to 37.1 to 36.9 (p=.003)

  21. Integrated care coordinator meets with SPMI (Health Home) patient a few minutes prior to physician entering the room to: assist pt in focusing on the top 3 issues he/she would like addressed today review logistics of PC: prepare pt about length of appt, any longer than anticipated wait times, etc. review pt’s mood, new stressors and any emotional issues that could be impacting physical health At the same time, physician reviews an interagency form: includes pt’s mental health diagnoses, psychiatric medications and any relevant notes from mental health team Health Literacy: Before the Medical Visit

  22. Integrated care coordinator stays with pt for the length of exam to: be a witness to the points of difficulty between pt and physician provide support to the physician should the pt experience difficulty communicating provide support to the pt should pt experience difficulty understanding medical concepts or recommendations Health Literacy: During the Medical Visit

  23. Health Literacy: After the medical visit

  24. Bottom Line • Integrated care must be infused into the core mission, values and commitment of an organization to be successful. • There is no right way to integrate, but there are known strategies that are evidence-based • Addressing the integrated care needs of the SPMI population is a challenge, but is no longer optional.

  25. Citations • Stranges, E. (Thomson Reuters), Levit, K. (Thomson Reuters), Stocks, C. (Agency for Healthcare Research and Quality) and Santora, P. (Substance Abuse and Mental Health Services Administration). State Variation in Inpatient Hospitalizations for Mental Health and Substance Abuse Conditions, 20022008. HCUP Statistical Brief #117. June 2011. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb117.pdf • Russo, C. A. (Thomson Healthcare), Hambrick, M. M. (AHRQ), and Owens, P. L. (AHRQ). Hospital Stays Related to Depression, 2005. HCUP Statistical Brief #40. November 2007. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb40.pdf

  26. Contact Information Nelly Burdette, PsyD Director of Integrated Care The Providence Center 530 North Main St Providence, RI 02904 Direct Office: 401/415-8820 Email: nburdette@provctr.org

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