Integrated Care: A MeHAF Project

1. Integrated Care:A MeHAF Project WHEN THE HEAD IS ATTACHED TO THE REST OF THE BODY Kathleen L. Webster RN, MSN PMHNP-BC

2. MEHAF GRANT • MaineGeneral ACT TEAM selected to participate in a 3 year Grant funded project with the Maine Health Access Foundation (MEHAF) • MEHAF’s Mission: • Promote affordable and timely access to comprehensive, quality health care • Improve the health of Maine residence

3. MeHAF GRANT • Systems transformation grant • Jan 1/09-Dec/11 • ACT TEAM one of 6 community agencies selected • Focus of grant-consumers with DX of SMI in addition to diabetes or metabolic syndrome

4. 6 Community Agencies • Common Ties • Crisis and Counseling • Kennebec Behavioral Health • MaineGeneral ACT TEAM • Motivational Services • Tri-County ACT TEAM

5. MeHAF GRANT • Key Objectives: • Link consumers to PCP • Care Management for consumers with SMI and chronic medical diseases • Peer Support systems enhanced or developed • Develop screening tools • Develop Tracking systems for clinical workflow • Training and education for both consumers and providers • Communicate and collaborate with policy makers

7. Amy McKenna Debbie McGuire Marc Gallant Susie Carlsen Jane Cloutier Renee Quirion Georgette Roy Sheila Worth Heidi Little Stacie Dennett Kathleen Webster MaineGeneral ACT Team Members • The ACT TEAM CLIENTS • Emilie Van Eeghen • Barbara Crowley • James Schneid • Nancy Weingarten • Susan Albano • Jessica Ruth • Louise Gephart • Nina Miller • Louisa Barnhart • Maria Beauregard

8. Target Population • MaineGeneral ACT Team 93-100 persons who are cared for by the ACT team in Augusta and Waterville participated in this grant project over a 3 year period. ACT team clients by definition have a severe and persistent mental illness as well as co-morbid substance use disorders and chronic medical illnesses.

9. Significance of Clinical problem • People with SMI die 25 years earlier than people without SMI • Average age of 53 years old • A Maine Study of Medicaid Recipients revealed 87% of lives lost to premature death are not due to suicide but rather chronic medical conditions Maine CDC 2004

10. SMI & Non SMI MaineCareMaine CDC 2004

11. Utilization of ServicesMaine CDC 2004

12. Diabetes & SMI- MaineCare SMI -$5,360 • NON – $3,930 • Double the prevalence • High risk – Smoking, Obesity, dyslipidemia • Less Access to a medical home • Poorer Outcomes Maine CDC 2004

13. Body-Mind-Spirit • Hypertension • Diabetes • Obesity • Cardiovascular Disease • Access to primary and specialty care often hampered • Poverty • Substance Use/Dependence inclusive of nicotine • Poor Nutrition • Inadequate exercise • Exposure to psychotropic medications • Stigma • Socially marginalized • Support System often limited to care providers • Disconnect between mental health and physical health care systems

14. IOM:6 AIMS for IMPROVEMENT • SAFE • EFFECTIVE • PATIENT-CENTERED • TIMELY • EFFICIENT • EQUITABLE • IOM, 2001

15. IOM: 10 RULES for REDESIGN • Care is based on continuous healing relationships • Care is Customized to patient needs & values • Patient is the source of control • Knowledge is shared & information flows freely • Decision making is evidence based • Safety is a system property • Transparency is necessary • Needs are anticipated • Waste is continuously decreased • Cooperation among clinicians is a priority • IOM, 2001

16. IOM:4 Areas of Redesign • Evidence Based Care • Utilization of Information Technology • Aligning Payment Policies with QI • Preparing the Workforce • IOM, 2001

17. ACT Team • MaineGeneral ACT Team Approximately 93-100 persons who are cared for by the ACT team in Augusta and Waterville participated in this grant project over a 3 year period.

18. COMORBID ILLNESSES

19. ACT TEAM COMORBID RATE

20. ED VISITS 12/09-11/11

21. Data A Run Chart was utilized to study one outcome related to ED usage. Time studied was 12/09-11/11 representing 24 data points representing time. The Number of ED visits by ACT team clients per month was manually counted and plotted against the time variant.

22. Data: Analysis & Interpretation • Test #1 Presence of too much or too little variable • There are 24 data points, excluding 1 point on the median, in which there are 9 runs. The probability table shows that with 24 points at least 8 runs are needed and no more than 17 therefore no special causes are present only common cause. • Test #2 Presence of a shift in the process • There are no runs with more than 4 data points, at least 8 are necessary to demonstrate a shift in the process therefore common cause only present • Test #3 • No evidence of a trend as there are no more than 4 consecutive data points

23. Data: Analysis & Interpretation • Common Cause Variation in the number of ED visits. • This number of visits is worthy of a change process for improvement • NOTE addition of 4 hours per week of FNP starting in July with an increase in communication and expectation of collaboration between the ACT team clinical/support staff and the PCP clinical and support staff.

24. Chronic Care Model • Community • Resources and Policies • Health System • Self Management • Delivery System Design • Decision Support • Clinical Information Systems • Productive Interactions • Informed, Activated Patient • Prepared, Proactive Practice Team • Outcomes • Improved Outcomes

25. Safe: Avoid injuries to patients from the care that is intended to help them Treatment Evidence Based Labs as per recommended protocols F/U w/ Psych Providers- Case Managers F/U w/ Medical Providers- Case Managers Avoid ED utilization as an intervention for Primary care needs – Access to PCP key

26. Effective: Provideservices based on scientific knowledge to those who would benefit - refrain from those not likely to ….. • One goal - to develop ways to track health issues and workflow • Development of a Screening Tool • Request report from MaineGeneral system related to ED visits

27. PATIENT CENTERED: Respectful and responsive to individual needs/values that guide the careThe 4 Quadrant Clinical Integration Model Quadrant I BH PH Quadrant III BH PH >PCP (screening tools/BH practice guidelines) >PCP based BH consultant/care manager >Specialty Med/Surg >Psychiatric consultation >ED >Med/Surg Inpatient >Nursing Home/Home based care >Community Resources samhsa.gov 2010 >PCP (screening tools & BH practice guidelines) >PCP based BH consultant/care manager >Psychiatric Consultation

28. 4 Quadrant Clinical Integration Model Quadrant IV BH PH Quadrant II BH PH >BH Clinician/CM coordinating with PCP >PCP (Screening tools/guidelines) >Outstationed medical provider at BH site >Specialty BH >Residential BH >Crisis/ED >BH Inpatient >Community Supports samhsa.gov 2010 >PCP (screening tools / guidelines) >Outstationed medical provider in the BH site >BH Clinician/case manager >External Care Manger >Specialty med/surg >Specialty BH >Residential BH >Crisis/ED BH/Med/Surg Inpatient >Community Supports

29. Timely and Efficient Tracking of consumers who access ED to notify provider in real time. Linking the screening tool to Clinical support tools Consumer Access of training options System that would notify team of pertinent thresholds labs BMI latest f/u per treatment guidelines Diabetes Screening and Treatment Recommended Labs eye exams foot exams

30. Equitable: care that does not vary in quality due to gender, ethnicity, geographic location, socioeconomic status Linking consumer to a welcoming PCP one of the primary intents of the MeHAF project. • At the end of the 3 year project • 100% of clients reported having a PCP • 80% reported having seen PCP in past year • 69% reported ED visit

31. OUTCOMES

32. Health Screen • Developed in the Second Year of the Project • Has increased the dialogues between team members, both clients and staff. • Has established some baseline data that is now informing the practice in the office. • Has created an opportunity for improved care outcomes • Has created an opportunity for integrated care concepts

33. Health Screen • Of 81 clients surveyed in the past 2 years • 53% have 5 or more co-morbid medical illnesses • 15% have 4 • 14% have 3 • 11% have 2 • 7% have 1 • 2% have none documented • 4 people have passed away in the past 15 months

34. Health Screen • In the first 12 months • 69 clients screened • 59% had BMIs > 25 • 38% had BP > 130/80 • 96% had a PCP • 86% seen in past 12 months • 44% seen in the ED for both mental health and medical care • The following 9 months • 64 clients screened • 61% had BMIs >25 • 25% had BP> 130/80 • 100% had a PCP • 80% seen in past 12 months • 69% seen in the ED for both mental health and medical care

35. Take Away • The dialogue with the client regarding their physical as well as mental health concerns increased in frequency and structure • A richer base for patient education was established • An increase in collaborative dialogues with health care providers in the community who are also caring for the ACT client • An opportunity to have an FNP 4 hours per week in the ACT team office as a result of dialogues with leadership bringing us closer to an Integrated Care Model

36. Next Steps • Formally establish health education groups in addition to 1:1 delivery of patient education • Establish a physical health group (2nd Y-Group started 2/12) • Increase FNP time at the ACT team office site to enable care for both Waterville as well as the Augusta Case Load • Continue to work on the Integrated Care Model as many clients see this as their medical home

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