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Learn about the impact of the Care Transformation Collaborative of Rhode Island on primary care through an integrated behavioral health program and community health teams.
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Advancing Comprehensive Primary Care: Through Integrated BH Program and Community Health Teams March 26th, 2019 Debra Hurwitz, MBA, BSN RN Executive Director Dhurwitz@ctc-ri.org
Expanding Comprehensive Primary Care • The Care Transformation Collaborative of Rhode Island has a growing impact across the state, and includes: • 106 primary practices, including internal medicine, family medicine, and pediatric practices. • Approximately 650,000 Rhode Islanders receive their care from one of our practices. • 750 providers across our adult and pediatric practices. • Investment from every health insurance plan in Rhode Island, including private and public plans. • All Federally Qualified Health Centers in Rhode Island participate in our Collaborative • $217 million reduction in total cost of care dollars in 2016 compared to non-patient centered medical homes in Rhode Island, according to data from the state’s All-Payer Claims Database. • 2019 Integrated Behavioral Health Expansion • July 2019 PCMH Kids Expansion
Integrated Behavioral Health Project Goals Goal 1: Reach higher levels of quality through universal screening Goal 2: Increase access to brief intervention for patients with moderate depression, anxiety, SUD and co-occurring chronic conditions Goal 3: Provide care coordination and intervention for patients with high emergency department (ED) utilization /and behavioral health condition Goal 4: Increase patient self care management skills: chronic condition and behavioral health need Goal 5: Determine cost savings that primary care can achieve by decreasing ED visits and inpatient hospitalization Target Audience(s): Ten Patient Centered Medical Home (PCMH) primary care practices serving 42,000 adults
Better Care - Lower Costs IBH Cohorts - CTC Non-IBH Difference of the Differences ∆ $47pmpm – Cohort 1 ∆ $43pmpm – Cohort 2 Data Source: Rhode Island All Payer Claims Database
Qualitative Evaluation Providers love it: “When I say how much I love having integrated behavioral health, it is that I can't imagine primary care without it. It just makes so much sense to me to have those resources all in the same place because it's so important. So I love it. I can't speak highly enough of it.” (Medical Provider) Value of deliberate screening: "I'm surprised especially with the anxiety screener that there's more out there than I knew about. I was talking to somebody yesterday. You think this wouldn't be useful information. I know the patient pretty well, and the patients, if they had an issue, I'm sure they would tell me. But it comes up on the screener." (Medical Provider) Impact on ED use: “One of the things we identified [through the program] was somebody was going to the ER almost every other day, and it was due to anxiety. So he was given tools to control that, and it actually empowered him. He felt like he had taken control of this issue. And his ER visits dropped right off. He was being seen here [at the primary care practice] more frequently, but that's okay. We'd rather he come here than go to the ER.” (Practice Coordinator) BEHAVIORAL
Main Takeaways Integrated Behavioral Health in Primary Care Works Improved access, patient care & reduces costs Onsite practice facilitation by IBH subject matter experts supports culture change for successful implementation • More action is needed • APM for Integrated Behavioral Health in Primary Care • No copays for behavioral health screenings • Eliminate second copay for same day visit • Continue workforce development
Community Health Teams and SBIRT (Screening, Brief Intervention and Referral to Treatment)Evaluation Data to Date
Funding Partners for CHT S I M
Our Implementation Partners Other Key Partners BROWN School of Public Health
Community Health Team Model – an extension of primary care • Use care management processes to address • Physical health needs • Behavioral health/SUD needs • Health education needs • Social determinants of health needs Community Health Team Community-Based Licensed Behavioral Health Professional (At least one) Community Health Worker (CHW) (At least two) SBIRT Screener (At least one) Community-Based Specialty Consultants or Referrals (Pharmacy, Nutrition, Legal)
SBIRT Overview Five-year grant from the Substance Abuse and Mental Health Services Administration (SAMHSA) Seeks to normalize screening for and conversing about substance use disorders Helps Rhode Island address the ongoing opioid epidemic Enhances CHTs with an evidence-based tool
CHT Clients Served N=271 collected from 7 CHTs between 10/1/18-1/31/19
90% of CHT Patients had at least 1 SDOH need at Intake N=271 collected from 7 CHTs between 10/1/18-1/31/19
CHT Patients at Intake Quality of Life Measure CDC Health-Related Quality of Life Measure Poor functioning due to Physical and/or Mental Health -17.4 days/30 days (sd=11.2) CHT clients report poor functioning over half the days of each month (N=231)
Wellbeing – Present + Future “Please imagine a ladder with steps numbered from zero at the bottom to ten at the top. The top of the ladder represents the best possible life for you and the bottom of the ladder represents the worst possible life for you.” Present Life Evaluation “On which step of the ladder would you say you personally feel you stand at this time?” • Thriving 7 • Struggling • Suffering 4 • 5 Future Life Evaluation “On which step of the ladder do you think you will stand about five years from now?” Cantril Self-Anchoring Striving Scale (Cantril, 1965) & GALLUP
Pre-Post Changes in Health Risk 43% decrease 43% decrease in RTT score, intake to discharge – 7 months in care
Changes in Anxiety and Depression PHQ9 GAD7 28% decrease in GAD7 score, intake to discharge, *p<.0001 31% decrease in PHQ9 score, intake to discharge, *p<.0001
Preliminary Results show decrease in patient costs Early results from Brown University matched comparison study show a decrease in total cost of care for CHT enrollees. Small sample size makes the results not statistically significant. Additional data from Thundermist being added to the analysis.
Male in his 50’s, immigrated from Liberia during the civil war. Experiencing chronic headaches and vertigo past 3 years. Symptoms caused him to lose job and stop driving. Many ED and specialist visits, no progress on treating/identifying cause of symptoms– pt. very frustrated. PCP wants him to go to psych, he refuses. No income, homeless-couch surfing, limited English literacy, kids in Africa rely on him financially. AGENCY CHT Case Study: 2018, Q3 Risk Drivers Triage Score: 22 Insurance: NHP Medicaid Utilization: 2016-2017 14 ED Visits Audiologist, Otolaryngologist, Gastroenterologist, 2 ENT’s, Neurologist, LICSW, Several Radiology visit. Health Conditions/Literacy: Chronic Headaches/Vertigo, very frustrated over failure to find effective tx. Care Coordination: PCP trying to figure out cause of Headaches/Vertigo, will not see psychiatrist Social/Emotional Support: Support from tight knit immigrant community. Children in Africa, Girl friend out state. Very spiritual. Functional Limitations: Can’t drive or work, English second language, stopped school after 4th grade, very limited English literacy. Psycho-Social Factors: Financial: No income. Lost job due to symptoms, exhausted unemployment and TDI Family: Stressed over inability to send money to support children in Africa, causing conflict Housing: Homeless, couch surfing Transportation: Walks to destinations Behavioral Health: PTSD, Depression Intervention Outcomes Utilization: Frequent PCP visits Health Conditions/Literacy: Health Coaching, Sinus surgery- no improvement reported post surgery, insurance would not cover Mayo clinic, saw faith healer in Africa Care Coordination: Coaching to appointments and follow PCP recommendations Social/Emotional Support: Very frequent visit and calls with CHW Functional Limitations: Regularly go through mail and documents with CHW, referred to GED classes Psycho-Social Factors: Family: Coached to focus on what he can control Housing: Assistance applying for subsidized housing Transportation: Taught how to use Logisticare Financial: Guided though SSDI process, lawyer referral Behavioral Health: Coached to partial hospitalization Current Triage Score: 11 Utilization: 2 ER visits in 2018, none for headache/dizziness Health Conditions/Literacy: Following PCP recommendations, going to acupuncture, reports improvement in symptoms. Care Coordination: Going to appointments Social/Emotional Support: Still checks in regularly with CHW and engaged with immigrant community. Functional Limitations: started driving again, enrolled in GED class over the summer. Psycho-Social Factors: Financial: Got SSDI on appeal Family: Paid for daughters’ school tuition, eased strain with family Housing: On list for public housing, has good priority standing Transportation: Starting to drive again, uses Logisticare as needed. Behavioral Health: Much improvement in mood.
Patients Say CHT Helped Them Acquire: • Whatever was needed: • “I pleaded with the electric company. ‘My mom will die without her oxygen. What am I supposed to do?’ And they're like, ‘Not our problem.’ So I called [CHT staff]. I was basically panicking. And she was like, ‘Nope, just let me handle it.’ And she just called them, and twenty minutes later the guy was right back -- turned it right back on.” • Psychological and substance abuse counseling • “[CHT staff person] just called all kinds of therapists until she could find one that had an opening that would take me because they're all, ‘Oh we're not taking new clients.’” • Food • Clothing • Furniture • Medical equipment • Correctly sized wheelchair • Nutrition information • Adult day care • Parenting classes • CNA • Legal representation • Affordable medication • Safer, nicer housing • Transportation • Medical information • Medical appointments • Benefits • Resources for family members • Utilities payment assistance
Next Steps • CHT • Promoting a multi-payer, statewide network that would serve a public utility by being payer blind • Working with EOHHS and AEs to determine how CHTs can help AEs and Medicaid meet requirements for: • * managing risk • * avoiding duplication of care coordinationefforts • * addressing BH and SDOH • SBIRT • - Funding SBIRT through 2021 via SAMHSA grant opportunity • Embedding ‘Train the Trainers’ into organizations doing SBIRT • Connection on OHIC Integrating BH Workgroup • Continuation of SBIRT Training and Resource Center under SOR
