A Student-Centered Medical Home Model for Integrated Student Health and Counseling Services

1. A Student-Centered Medical Home Model for Integrated Student Health and Counseling Services ACHA, Friday, May 30, 2014, 1:45-2:45 Thomas J. Ferguson, M.D., Ph.D. Dorje M. Jennette, Psy.D.* Michelle Famula, M.D. Cory N. Vu, O.D. Sarah Hahn, Ph.D. Sandy Santiago *now at UC Santa Cruz

2. Define Student/Patient -Centered Medical Home (PCMH) • Describe models for provision of behavioral health services in a PCMH model • List examples of collaborative care • Identify opportunities for suicide prevention • Synergies: Access, engagement, & screening Objectives Speaker: Tom Ferguson, MD, PhD, Medical Director, UC Davis SHCS

3. Student-Centered Medical Home Model Speaker: Cory Vu, O.D., Quality Improvement/Risk Manager, UC Davis SHCS Patient-centered Medical Home (PCMH), is a team based health care delivery model led by a PCP that provides comprehensive and continuous medical care to patients with the goal of obtaining maximized health outcomes.The provision of medical homes may allow better access to health care, increase satisfactionwith care, and improve health. http://en.wikipedia.org/wiki/Medical_home

4. Student-Centered Medical Home Model Speaker: Cory Vu, O.D., Quality Improvement/Risk Manager, UC Davis SHCS http://parkwaymedicalgroup.com/patient-centered-medical-home/

5. Communication Speaker: Cory Vu, O.D., Quality Improvement/Risk Manager, UC Davis SHCS

6. Student-Centered Medical Home Model Speaker: Cory Vu, O.D., Quality Improvement/Risk Manager, UC Davis SHCS

7. Why PCMH in a Student Health Center? Speaker: Cory Vu, O.D., Quality Improvement/Risk Manager, UC Davis SHCS

8. Healthy Campus 2020 Speaker: Cory Vu, O.D., Quality Improvement/Risk Manager, UC Davis SHCS • Healthy Campus 2020 Overarching Goals • Create social and physical environments that promote good health for all. • Support efforts to increase academic success, productivity, student and faculty/staff retention, and life-long learning. • Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death. • Achieve health equity, eliminate disparities, and improve the health of the entire campus community. • Promote quality of life, healthy development, and positive health behaviors. American College Health Association - Task Force on National Health Objectives

9. UC Davis SHCS • Intermediate stages of integration, the initial stages having involved an organizational and electronic health record merge • Mission statement excerpt: “…providing an integrated program of quality, accessible, cost sensitive and confidential healthcare services, tailored to [students’] unique and diverse needs…” • Medical Home certification in addition to general AAAHC accreditation Context of Implementation Speaker: Michelle Famula, M.D., Executive Director, UC Davis Health & Wellness

10. Counseling Services • Individual/GroupCounseling • Drop-in Consultations • Career Counseling • Specialty Care • Psychiatry • Urgent Care • Integrated Medical/Mental Health Student Health and Counseling Services Speaker: Michelle Famula, M.D., Executive Director, UC Davis Health & Wellness Accreditation: AAAHC, IACS & APA • Primary Care • Open Access Appointments • Assigned PCPs • Patient CenteredMedical Home • Outreach andPeer Programs • Health Promotion • Self Help Services

11. Student Health and Counseling Services Speaker: Michelle Famula, M.D., Executive Director, UC Davis Health & Wellness • 70,740 SHCS Visits • 51,657 Medical Service Visits(Primary, Specialty and Urgent Care) • 19,083 Mental Health Visits(Psychology and Psychiatry) • 17,381 Unique Students Served • 15,850 Unique medical patients • 4,359 Unique mental health clients • 17% received care from both medical and mental health

12. Goal 1: Enhanced Organization Integration: Strategic Planning: Initiatives Speaker: Sandy Santiago, Director of Clinic Support Services, UC Davis SHCS A single organization committed to working together to serve students with every staff member aware of all available services, freely accessing and sharing information for the holistic care of students. Objective 1: Develop a common framework for administrative services Objective 2: Create fully integrated clinical services Objective 3: Integrated Outreach program across Medical/Mental Health

13. Every UC Davis Student has a team of professionals to help them (i.e., a “Medical Home”) and they understand how to access services. Professionals support one another in this endeavor and there is effective communication among providers in a uniform manner All are on the same computer network and electronic health record (EHR) Traditions are maintained, built upon with joint training and professional development to enhance communication There are clear administrative policies with respect to services as well as human resources. Strategic Planning: Expected Outcomes Speaker: Sandy Santiago, Director of Clinic Support Services, UC Davis SHCS

14. Executive Support Gathering input Staff Champions EDMT pilot – shared record Practical Aspects of Implementation Speaker: Sandy Santiago, Director of Clinic Support Services, UC Davis SHCS • Clinical Staff Integration Meetings • Increase communication • Build relationships • Learn to understand each other • MOD/POD Shared/Common Training brief motivational interviewing suicide risk assessment

15. Suicide Prevention Speaker: DorjeJennette, PsyD, CAPS Clinical Director, UC Santa Cruz Student Health • Nationally, professional health care is underutilized among those who are at risk of completing suicide (e.g., Luoma, Martin, and Pearson, 2002) • Integration has the potential to unlock synergies that help students access and adhere to the care they need • Risk screening and safety planning—casting a wider net

16. Suicide Prevention Speaker: DorjeJennette, PsyD, CAPS Clinical Director, UC Santa Cruz Student Health • Students with gender identity stressors associated with elevated suicide risk and low health services engagement • Bringing engagement to vulnerable populations: Community Advising Network • Psychotherapists embedded in partner units such as the LGBTQIAQ center • Establishing trust and bridging to medical services

17. Quality Review: Continued discipline-specific peer review and quality assurance teams, but formed integrated umbrella Quality Committee Treatment/Consult: Continued department-specific treatment teams, but formed integrated: Eating Disorder Management Team Behavioral Health Consultation Team ATOD Consultation Team Multidisciplinary Teams Speaker: DorjeJennette, PsyD, CAPS Clinical Director, UC Santa Cruz Student Health

18. Students with Eating Disorders • Care team that regularly communicates/collaborates • Unambiguous level-of-care recommendations • Students with ATOD concerns • Care team that trained together in motivational interviewing • Prescriber boundaries clear among providers and their patients • Transgender Students • Unified designation of gender identity in EHR • Streamlined transfer of documentation • ADHD • Standardization and improved validity in diagnoses • Reduced wait time for access to psychiatry Collaborative Care Speaker: DorjeJennette, PsyD, CAPS Clinical Director, UC Santa Cruz Student Health

19. Richard Fee “Drowned in a Stream of Prescriptions” -NYT Speaker: Dorje Jennette, PsyD, CAPS Clinical Director, UC Santa Cruz Student Health

20. ETS standards for accommodations on SAT/GRE an evaluation within the last three years by a specialized psychologist/psychiatrist with first-hand childhood teacher comments, third-party evidence of current impairment, a rule-out of alternative diagnoses, and relevant testing (e.g., intellect, achievement, processing speed, fluency, executive functioning, language, attention, and memory) Emerging Standards for ADHD Diagnosis Speaker: DorjeJennette, PsyD, CAPS Clinical Director, UC Santa Cruz Student Health • NCAA standards for athletes testing + for stimulants • Less specific than ETS, butgenerally similar. • UCSB’s Elizabeth May, PhD, and Edwin Feliciano, MD • September 2012 UC-wide conference call • Emphasized the need for symptom validity testing, which helps distinguish between malingering/inadequate effort and true impairments/symptoms

21. ADHD Screening Process Speaker: DorjeJennette, PsyD, CAPS Clinical Director, UC Santa Cruz Student Health Psychiatry, Psychotherapy, Full Testing Battery, PCP, and/or Learning Resources

22. Retrospective chart review for subjective report of improvement for patients treated medicallyStarted onPositive Response ADHD Treatment 30/32 = 94% Anxiety/Depression Treatment 30/35 = 86% Outcome of Treatment Speaker: DorjeJennette, PsyD, CAPS Clinical Director, UC Santa Cruz Student Health

23. Improved accuracies in evaluation Identification of true cause of symptoms/distress Better academic outcomes (presuming treatmentimproves attention which improves effective studying) Reduced risk of abuse Efficiencies; better allocation of resources Establishing consistency/standards of practice Benefits of ADHD Screening Speaker: DorjeJennette, PsyD, CAPS Clinical Director, UC Santa Cruz Student Health

24. Triage system Urgent Care (Shared Medical/CAPS) Resource Coordination Medical Officer of the Day (MOD) – Experienced physician is available by pager for second opinion and to assist Urgent Care as a resource for psychologists and PC Providers Psychologist of the Day (POD) – Experienced psychologist who is available by pager to assist PCP and UC Triage Nurses in risk assessment and crisis response. ‘Warm Handoffs’ – POD can meet and greet patient in UC or PC clinics to introduce and arrange appointment later in day or week (or can assess urgently). Integrated Urgent Care Speaker: Tom Ferguson, MD, PhD, Medical Director, UC Davis SHCS

25. CASE: UC patient assessed by RN for feeling anxious. Has hypertension 148/110 and HR 90 with past medical history of bipolar disorder and recently poor sleep. Past medical history of psychosis and hospitalizations for bipolar disease. Triage RN identified acute medical and psychological assessment needs MOD requested POD to assess for patient safety concerns likely exacerbation bipolar disorder and previous hospitalizations Psychologist assessed and diagnosed bipolar disorder needing higher level of care. Patient agreed to voluntary psychiatric hospitalization for acute care. Was normotensive at discharge from inpatient treatment without any antihypertensive treatment but was taking medications for bipolar treatment. Integrated Urgent Care: Case Study Speaker: Tom Ferguson, MD, PhD, Medical Director, UC Davis SHCS

26. CASE: 23 yo male seen by PCP for ankle injury and as part of that visit is screened for depression with PHQ 9. Score elevated at 21 with question 9 indicating daily thoughts of self harm. PCP does screening for suicide (ACP P4 screener) which scores low for immediate risk and reviews concern with POD. POD facilitates assessment using warm handoff technique and initiates therapy with messaging to PCP. Coordination of care and warm handoff improves likelihood of formal psychological assessment and engagement in care. Collaborative approach in making treatment decisions (don’t all need medications but do all need monitoring !). Another Case Study Speaker: Tom Ferguson, MD, PhD, Medical Director, UC Davis SHCS

27. CASE: 19 yo female international student assessed by CAPS psychologist and determined to have recurrence of severe depression. Had stopped fluoxetine when came to USA 6 months ago. Not suicidal but difficulty getting out of bed and academic problems. Next initial psychiatry appointment in 4 wks. Psychologist pages MOD for consultation. MOD discusses case with the psychologist regarding best care for patient. PCP appt 24 hours is decided – PCP copied on notes from MOD and psychologist so is expecting the patient in clinic. Coordination cuts through ‘red tape’ and ‘bottlenecks’ Does require PCP willingness to initiate and monitor therapy for depression. PCP collaborate with psychiatrists via secure messaging for support. Warm Handoffs Work Both Ways ! Speaker: Tom Ferguson, MD, PhD, Medical Director, UC Davis SHCS

28. Communication Speaker: Tom Ferguson, MD, PhD, Medical Director, UC Davis SHCS

29. Importance of change management/rolling with resistance: communication/processing/discussion Strategic planning is critical to put leaders on the same page Participating in CSI/workgroups/team meetings helps sharing, communication, and understanding across disciplines Keep student-centered perspectives in mind (e.g., complex/high-risk students might be best served at times by a one-stop integrated urgent care service) Lessons Learned Speaker: Michelle Famula, M.D., Executive Director, UC Davis Health & Wellness

30. Open Access scheduling for psychological services Alcohol screening/CCAPS tracking ATOD team development; smoking cessation integration More systematic referrals of patients from psychiatry to PCP for stabilized med management (with consultation available), conserving limited psychiatry resources. What’s Next? Speaker: Michelle Famula, M.D., Executive Director, UC Davis Health & Wellness

31. Discussion/Questions/Contact Us Thomas Ferguson, MD, PhD Medical Director tferguson@shcs.ucdavis.edu Dorje Jennette, PsyD CAPS Clinical Director, UCSC jennette@ucsc.edu Michelle Famula, MD Executive Director mfamula@shcs.ucdavis.edu Cory Vu, OD Quality Improvement/Risk Manager cvu@shcs.ucdavis.edu Sarah Hahn, PhD CAPS Director shahn@shcs.ucdavis.edu Sandy Santiago Director of Clinic Support Services ssantiago@shcs.ucdavis.edu