Integrated Primary Care Program New England Rural Health Roundtable Maryagnes Gillman

1. Integrated Primary Care Program New England Rural Health Roundtable Maryagnes Gillman October 30, 2009 Sacopee Valley Health Center

2. Sacopee Valley Health Center • Location - Porter, Maine • Opened in 1976 • Federally Qualified Health Center • Patients – 4,300 • Encounters – 17,000 • Total staff – 45 • Serves 12 rural towns in 4 counties & two states (Maine & New Hampshire) • Service area population of + 20,500 Sacopee Valley Health Center

3. SVHC Sacopee Valley Health Center

4. Sacopee Valley Health Center

5. 3 family practice physician – 2.25 FTE’s 1 pediatrician – 1FTE 2 physician assistant – 1FTE 1 family nurse practitioner – ½ day/week 1 behavioral health consultant - LCSW 1 care manager – BA 1 MMCPHO care manager - RN 1 pediatric psychiatrist- one day/week 6 mental health program staff Sacopee Valley Health Center Sacopee Valley Health Center Sacopee Valley Health Center

6. Family Medical Care Pediatric Psychiatry Mental Health Counseling Substance Abuse Counseling Integrated Behavioral Health Nutrition Counseling Podiatry Prepared Childbirth Classes Community Health Education Care management Optometry Family Planning Social Services Coordination Fee Discount Program Patient Assistance Program (for chronic meds) MaineCare (Medicaid) Enrollment Assistance Programs & Services at SVHC Sacopee Valley Health Center

7. The beginning • Sacopee Valley Health Center was founded in 1976, and had co location of mental health services beginning in 1978 with: • Psychiatric Social Worker • Alcoholism Counselor • Drug Abuse Counselor Contracted with York County Counseling Services (became Counseling Services, Inc.) Sacopee Valley Health Center

8. 1978-2005 • Through the years there were several LCSWs and clinical psychologists who worked at SVHC under contract. • The first clinical psychologist employed by SVHC was in 1997, and Dr. Jeffrey Krebs assumed that position in 1999. Sacopee Valley Health Center

9. Co-location at SVHC This was the model used until 2004 when we began to look at a more integrated model after a staff member heard a presentation by Kirk Stroshal. Sacopee Valley Health Center

10. Kirk Stroshal • BPHC funded 2 day site visit to SVHC in Fall 2004 • Trained all staff in the rudiments of Integrated Primary Care Sacopee Valley Health Center

11. 2004 • Work group formed to study viability of Integrated Primary Care at SVHC • Work group members from every department of the Health Center • Goal – clinical efficacy and financial/fiscal viability Sacopee Valley Health Center

12. Work Team 2004 • Director of Mental Health Services • Finance Billing Staff • Medical Director • Director of Allied Health Services • Front Office Staff • Administrative Secretary • Executive Director Sacopee Valley Health Center

13. IntegratedPrimary Care at SVHC • Based on the Strosahl model of integration • Stroshal model – utilizes a behavioral health consultant • 1-3 consult visits in typical case • 15-30 minute visits to mimic primary care pace and promote visit volume • Chronic condition pathways may require additional protocol driven visits • Uses classes and group medical appointments to increase volume & depth of intervention • High risk, high need patients seen more often as part of team based mgmt plan • 2005 was kick off - after planning year Sacopee Valley Health Center

14. 2005 • Behavioral Health Consultant began seeing patients in September 2005 • Needed to learn the role – lots to unlearn • Focused on self management and activation • Evidenced based tool kit • “What do you think you can work on?” • Primary Care providers needed to refer patients to be seen • Using Codes for Health and Behavior Assessment/Intervention 96150-96155 • Using PHQ9 Sacopee Valley Health Center

15. 2006 • Developed standing orders for patients • HTN BP >140/90 • Diabetes HbA1c >7 • Depression PHQ9 >9 • Patient satisfaction with program • Tracking provider referrals • Added classes to program • Stress reduction • Living well with ongoing conditions • BHC is housed in medical wing of the building • BHC schedule is on primary care provider monthly schedule • Member of primary care provider team Sacopee Valley Health Center

16. 2007 • Program continues to evolve • Targeted focus on diabetes • New providers on staff need to learn process • Medical providers went live with EMR • BHC using EMR exclusively for notes • Doing cold calls to patients while they are waiting to be seen • PHQ9 use continues • BHC now a direct report to medical director Sacopee Valley Health Center

17. 2008 • MeHAF funding awarded for program expansion • Add additional screening tools DUKE, SOAPP, MDQ, COMM, PSC, GAD7, CAGE-AID and PC-PTSD • Use laptops for patients to enter their own data regarding screening tools • Add care management functions to program Sacopee Valley Health Center

18. 2008 Continued • Engage the shadow health care network • Use libraries as a spread strategy • Establish a patient and family council focused on integration and care delivery Sacopee Valley Health Center

19. 2009 • Problem Solving Treatment – Primary Care • Huddles • Warm hand offs • Curbside Consults • Screenings • Standing orders • Referral trolling • Role differentiation Sacopee Valley Health Center

20. Primary success of PST is the patient learning new skills to approach problems.Give a man a fish he eats for a day; teach a man to fish and he eats for a lifetime. Sacopee Valley Health Center

21. Project Team 2009 Donna Burke Marty Braga Jeff Ray Jeffrey Krebs Maryagnes Gillman April Clark Amy Richardson Sacopee Valley Health Center

22. Role DifferentiationBHC – Care Manager – MH Counselor • BHC – billable 1:1 visits • Care Manager – phone call follow-ups, shadow health care network, libraries, meets with new patients, CPEs, well child checks, Pt and Family Council • MH Counselor – traditional mental health counseling Sacopee Valley Health Center

23. 2005-2009 • Ongoing staff training • During interview process for potential hires • All staff meetings • Individualized team meetings • Methodologies have included • Written materials • Didactic presentations • Role play • Outside experts Sacopee Valley Health Center

24. Philosophy of Integration • Holistic • Routine part of care – connecting head to body • Focused on wellness • Self management • Communication Sacopee Valley Health Center

25. Patient Satisfaction Sacopee Valley Health Center

26. Patient Satisfaction • Collected since the beginning. • Has evolved based on our experience and information learned as part of MeHAF Quality Counts project. Sacopee Valley Health Center

27. New Patient Satisfaction SurveyImplemented Sept 1, 2009“Give us a Grade” Sacopee Valley Health Center

28. GIVE US A GRADE Integrated Primary Care • The staff at this facility works well together and communicates with each other about my care. 3.77= A- • I receive respect from the staff that provides my care. 3.85 = A- • I am involved in the development of my plan of care. 3.81= A- • As a result of receiving integrated care, I believe my health has improved and I am taking better care of myself. 3.69 = B+ • As a result of receiving integrated care, I am better able to do my usual activities, such as work or school and recreation. 3.82 = A- Sacopee Valley Health Center

29. Provider Satisfaction Sacopee Valley Health Center

30. Quality Counts PilotProvider Satisfaction • As a result of our efforts to integrate clinical care: Worsened – Stayed the Same – Improved 1 - 2 - 3 - 4 - 5 • My job satisfaction has = 4.63 • The care provided to our patients has = 4.63 • Communication between the medical and behavioral staff regarding our patients’ plan of are has = 4.63 Sacopee Valley Health Center

31. Results Sacopee Valley Health Center

32. Self Management Goal Setting *Jul 09 – Number of pts with depression increased from 562 patients to 813 patients thus the decrease in SMG Sacopee Valley Health Center

33. UDS Measure 2009 BPR • By 2010, increase % of adults patients, age 18 and older who have completed one PHQ9 from 12.1 % (2008 –baseline calendar year) to 25%. • Current results Sept 2009 = 18.3% Sacopee Valley Health Center

34. August 2009 • Milestones • Care manager meeting with new patients • Care manager meeting with patients scheduled for CPE’s and Well Child Checks • Patient and Family Council first meeting • BHC and Care Manager meeting weekly with Medical Director • Revitalized classes – Zucchini Fest Sacopee Valley Health Center

35. Zucchini Fest Sacopee Valley Health Center

36. Patient and Family Council • First meeting held August 26, 2009 • Council has seven members • Meetings facilitated by our Care Manager and Health Educator • Project specific assignments – lobby • Next Project – How would patients liked to be surveyed about satisfaction? Sacopee Valley Health Center

37. Billing • LCSW providing this service • Using 96150-96155 • Health and Behavior Assessment/Intervention Codes Sacopee Valley Health Center

38. Sacopee Valley Health Center

39. Speed Bumps • EMR Implementation • Classes • Paradigm shifts – medical providers & BHC/Care manager and patients • Segue scripts – adherence • Over optimism – warm hands offs • Cold calling difficulties • Role clarification • BHC 4 visit limit • Not Mental Health crisis service Sacopee Valley Health Center

40. Next Steps • Pain Program • Schedule II medications • Benzos • Sleepers • Insomnia - CBT Sacopee Valley Health Center

41. We believe that we have come a long way in putting head back on the body and treating the whole person! Sacopee Valley Health Center

42. Questions? Sacopee Valley Health Center

43. Sacopee Valley Health Center 70 Main Street Porter, Maine 04068 Mailing address: PO Box 777 Parsonsfield, ME 04047 Contact: Maryagnes Gillman – mgillman@svhc.org 1-207-625-8129 ext 164 Sacopee Valley Health Center