Integrated Health Care: Behavioral & Primary Care Integration at Terry Reilly

2. Integrated Health Care Integrating Behavioral Health and Primary Care at Terry Reilly 2018 Andrew Baron, MD, MBA, FAAFP, CPE Chief Medical Officer

3. Terry Reilly Health Services A Federally Qualified Healthcare Center Has been serving our Idaho communities for over 45 years 14 sites--Medical, Dental, & BH 35K+ unique patients served; 175K visits Budget $26+ million annually 400 employees; 69 Prescribers BHCs (MSWs), Counselors, Physicians, NPs, PMHNPs, PAs, Dentists, Dental Hygienists

4. Patients 80% 100% below FPL 90% below 200% FPL Average collected per visit $27 55% without insurance 12% commercial insurance Rest Medicare and Medicaid Lower cost of care and top 5% Quality Board of Directors must have Patients on it BRIEF TITLE, MONTH, YEAR

5. Terry Reilly Health Services • Behavioral Health & Primary Care Integration Continues to be a work in progress • Organization is Committed to Integration • Organization is Committed to PCMH • NCQA level III and Joint Commission accredited PCMH • NCQA and Joint Commission accredited BHH

6. Terry Reilly Health Services • 7 Clinics medical/behavioral health • Nampa (PC & BH), Boise (PC & BH) level IV/V • Caldwell (PC & BH 5 days/wk}) level III/IV • Middleton (PC & BH 1 day/wk}) level III/IV • Homedale, Marsing, and Melba have PC and occasional BH with Telepsychiatry level III/IV

7. PC & PMHNP Primary Care Providers care for mental health patients PCPs Provide >80% of diagnosis and medication management Refer patients for counselling Complicated MH patients are referred to PMHNPs and our Psychiatrist PCPs consult PMHNPs and Psychiatrist & MSW

8. Heath et al: A Review and Proposed Standard Framework for Levels of Integrated Healthcare, Washington, DC, SAMSHA-HRSA Center for Integrated Health Solutions. March 2013 • Six Levels of Collaboration & Integration for BH & PC Coordinated: key element is Communication • Level I Minimal Collaboration • level II Basic Collaboration at a Distance Co-located: the Element is Physical Proximity • Level III Basic Collaboration on-site • level IV Close Collaboration on-site with Some System Integration Integrated: key element is Practice Change • Level V Close Collaboration Approaching an Integrated Practice • level VI Full Collaboration in a Transformed/merged Integrated Practice

9. Low levels of Integration • Coordinated: key element is Communication • Level I Minimal Collaboration • separate facilities, separate systems; driven by provider need not patient need or issue ,don't meet in person, limited understanding of roles, BH & PC separate • level II Basic Collaboration at a Distance • separate systems, communicate periodically about shared patients, communication is driven by specific patient issues, appreciate others' roles as resources

10. Heath et al: A Review and Proposed Standard Framework for Levels of Integrated Healthcare • Co-located: the Element is Physical Proximity • Level III Basic Collaboration on-site • same facility but not same offices -- separate systems, communicate regularly about shared patients by phone or e-mail and meet occasionally in person to discuss cases, collaborations; driven by the need for each others services and a more reliable referral, feel part of a larger yet ill-defined team • level IV Close Collaboration on-site with Some System Integration • same space within the same facility, share some systems like scheduling, medical records, communicate in person as needed, collaborations; driven by the need for consultation in coordinated plans for difficult patients, regular face-to-face interactions about patients, basic understanding of roles and cultures

11. Transformed integrated practice • Integrated: key element is Practice Change • Level V Close Collaboration Approaching an Integrated Practice • same space within the same facility with some shared space, actively seek system solutions together, communicate frequently in person, collaboration is driven by the desire to be a member of the team, regular team meetings, in-depth understanding of roles and cultures • level VI Full Collaboration in a Transformed/merged Integrated Practice • same space within the same facility sharing practice space, function as one integrated system, consistent communication at the system team and individual levels, collaboration is driven by the shared concept of team care, have formal and informal meetings to support integrated model of care, have roles and cultures that blur or bend

12. The level of Integration Has Implications for: • Clinical Delivery & Communication • Seamless vs barriers • Coordinated vs non • Shared clinical guidelines & vision • Communication between providers occurs • Flag, Telephone call, In person, Case staffing • Patient Experience • Patient Centered vs Clinician Centered • Practice organization • Staffing, physical layout, teams • Business Model

13. Terry Reilly has varying levels of integration within practices depending on clinic site • Small Rural Clinics • Have limited behavioral health resources available and are operating on a level III/IV integration • Counselor is available 1 day a week in our Middleton clinic but there is no psychiatric nurse practitioner available

14. Large Urban Clinic More highly integrated Operating on a level IV/V integration Our Boise clinic: Psychiatrist, PMHNP, case manager & BHCs are co-located with our PCPs, MAs and RNs.

15. Our Boise Clinic Integration • Pod Concept • Physical co-location • Most integrated behavioral health and primary care practice with the teams interacting on a continuous basis during delivery of care • Monthly meetings for the entire clinic at which BH and PC teams attend • Monthly meetings specifically centered around BH and PC integration • Include process improvement, and specific case reviews of complicated patients

16. Our Boise Clinic Integration • The pod concept with co-location of all BH and PC team members allows for interaction and collegiality as well as curbside consults on a regular basis • By having BH and PC integrated it allows: • patient needs can be met effectively by multiple disciplines that comprise the patient team • Patient with depression seen by Psychiatrist/PMHNP and BP is elevated; PCP initiates BP management that same day. • PCP has a patient that is suicidal; immediate access to a BHC (counselor) who can do an assessment of the patient and determine disposition in concert with PCP/PMHNP.

17. Traditionally Terry Reilly has had 3 Divisions Medical Behavioral Dental

18. Transformation from a Silo Organization to an Integrated Organization . • Committees Restructured • Quality Management Council • representatives of each “division” participating and accountable • Performance Improvement/Incident Reporting • Pharmacy and Therapeutics committee • Operations • We've evolved into corporate committees from silo committees

19. EHR • We use the same electronic health record for PMHNPs/Psychiatrist & PCPs as well as for social workers/BHCs/counselors • Templates and guidelines • PHQ-2, 9; GAD-7, MMSE, DSM-5 Cross Cut tool • ENLI Population Health Management software

20. PC and BH Integration BH and PC use a shared formulary Clinical guidelines for treatment of psychiatric illness continue to be developed Joint CME Regular communication between PC and behavioral health for patient issues, results, and treatment; Patient case staffing

21. Reporting Structure PCPs and PMHNPs report to the CMO (through medical directors) Clinical quality is monitored by the CMO for consistency of clinical standards Clinicians do chart reviews of each other Joint BH-PC documentation templates

22. Integrated Referral Process • We have an coordinated, closed loop referral process • Regular reports/discussion/flags • PMHNP to PC and PC to PMHNP • Counselor or BHC to PC and PC to Counselor

23. Transitions of care • Hospital discharges • New patients • BH patients that have medical needs • PC patients that have BH needs • Pediatrics & OB that have BH needs • Dental patients that need BH or PC • PHQ-2 for all Dental Patients • Healthcare for the Homeless clinics • Coordinated intakes with PC and BH

24. Transitions of Care • Allenbaugh Hospital Managed by Terry Reilly Health Services Integrated and coordinated discharge planning and follow-up at Terry Reilly Boise clinic Communication between AH and Boise clinic EHR access for AH; documentation immediately scanned into electronic record by AH

25. Transitions of Care • Psychiatric Hospital Discharges • Case manager reviews patients who are inpatient and require discharge follow-up with TRHS • Psychiatric facilities communicate with our case managers to ensure needed follow-up • Patients are seen either by BH or PC depending on availability

26. Transitions of Care • Healthcare for the Homeless at Boise clinic • Integrated approach for homeless healthcare • New patients are screened by an RN • Identified primary need BH and/or PC • Patient is seen by either BH or PC to have their greatest need attended to • Then they are seen by either BH or PC to have their other needs attended to if indicated • Medication samples are available for psychiatric meds and other medications are sent to the Boise clinic for patient pickup from TRHS pharmacy

27. Our Goal at TRHS: Seamless, Integrated, Patient Centered Care where Patients are Engaged and Partners With Us

28. Thanks! • Questions? • Andrew Baron, M.D. • abaron@trhs.org