Heal the Patient, Not the Symptoms

1. Heal the Patient, Not the Symptoms Michael Israel, MD Chief Medical Officer, Bluestem Health

2. Conflicts • None

3. Objectives • Review where medicine has been • Look at where medicine is going • Understand different integrated models • Discuss implementation of integration • Discuss potential problems with integration • Discuss why integration is integral in patient care

4. Objectives “Take the time to DEFINE the bottom line! What outcome do you desire?”

5. Medicine – The Old Ages • Fee for service • 46 y/o M with DM and an a1c 12 (goal <7) • Diet, exercise, start meds • Return visit shows a1c 11.9 • NON-COMPLIANT  ?Fired • Quality took a back seat

6. How do we fix this? • Increase the importance of Quality Measures • Add bonuses? • 46 y/o M with DM and a1c 12 (goal <7) • Found out they have bipolar, anxiety, hx of sexual abuse, high risk sexual behavior, smokes 2 packs of cigarettes daily, drinks 1 pint of whiskey nightly, can not “afford” 4 dollar meds – not taking meds regularly

7. WHAT JUST HAPPENED?!?! • 10-15 min appt for a DM check • Went from 1 dx 8 dx • I AM NEVER DOING THAT AGAIN!!! • Physician Burnout

8. Why Should We Do It Again? • Better Care, Better Care, Better Care!!!! • If we don’t, who will? • Undected and untreated/undertreated • Decreased access to mental health • Stigma • Decreased life expectancy, otherwise • Increased cost to health care, otherwise

9. How do we fix this? • Decrease patient panels and increase appointment times • Not enough primary care physicians in the WORLD • Join Accountable Care Organizations/Managed Care Organizations (ACOs/MCOs) • Integrated Care

10. What is Integrated Care? • Integration of services in which providers work together through shared services to achieve a common goal • Specifically for today’s talk: integration of primary care providers and mental health care providers and patients working together on a patient-centered approach • Vertical vs Horizontal Integration of care

11. Focused Integrated Care • Organizational Integration vs Organizational co-ordination

12. What did we do about it? • Bluestem Health partnered with Lutheran Family Services ~ 2014 • Started with Health 360 – mix of organizational co-ordination and integration • ~2016 added behavioralists to other locations and psychiatry on board

13. 2017 “Take the time to DEFINE the bottom line! What outcome do you desire?”

14. 2017-Present • Overhauled scheduling process • Took 2 days of the entire staff in April to train on the Cherokee Model of Integrated Care

15. Current Flow PCP BHC Psych

16. 2017-Present • Added appropriate and visible staffing • Defined Roles • PCP • BHC • Psych • Patient • Defined Expectations of all providers – primary care and behavioral health • Get the right people on the bus

17. 2017 – Present • Incorporated behavioral health into our provider meeting. • Monthly Goals • Monthly Progress Reports  Quarterly • Continuous reassessments • Emphasis on QA department

18. Pitfalls?

19. Pitfalls we Avoided • Part of our mission statement • “To be a trusted resource for excellent medical, dental and behavioral health services” • Integrated Space • Diminished Language Barriers

20. Pitfalls we Avoided • EHR Usage and scheduling • Reimbursements (kind of)

21. Pitfalls we did not Avoid • Hard to teach and old dog new tricks • Timing to see patients and hold-ups in the rooms • Didn’t use psych appropriately

22. Pitfalls we did not Avoid • Reimbursement (Kind of) • Enough BHCs • Excessive dependence

23. Outcomes • 2016 calendar year– ranked low-800s/~1381 in UDS data • Childhood Immunizations • Cervical Cancer Screening • Colorectal Cancer Screening • Depression and follow-up Screening • Patients with controlled HTN • Patients with DM with an a1c > 9 or no testing that year

24. Outcomes April 2017 August 2019 • Childhood Immunizations • 39% • Cervical Cancer Screening • 31% • Colorectal Cancer Screening • 18% • Depression and follow-up Screening • 64% • Childhood Immunizations • 45% • Cervical Cancer Screening • 49% • Colorectal Cancer Screening • 48% • Depression and follow-up Screening • 91%

25. Outcomes April 2017 August 2019 • Patients with controlled HTN • 59% • Patients with DM with an a1c > 9 or no testing that year • 47% • Patients with controlled HTN • 67% • Patients with DM with an a1c > 9 or no testing that year • 28%

26. Outcomes • 2018 Calendar year – ranked mid-100s/~1381 in UDS data • About 650 spot jump

27. Upcoming Outcomes • We have added SBIRT trainings and are piloting different ways to implement these trainings and how to measure outcomes

28. Conclusion • We have to recognize that mental health stability is critical in overall well-being • We can not continue to practice the old way if are truly expecting change • Integration is not a one-size fits all and is continuously fluid, but can result in better outcomes towards healing the patient as a whole

29. Conclusion “Take the time to DEFINE the bottom line! What outcome do you desire?”

30. Questions???

31. Bibliography • https://insights.ovid.com/medical-care/mcar/2011/06/000/understanding-excess-mortality-persons-mental/11/00005650 • https://medcitynews.com/2018/09/vertical-integration-in-healthcare/?rf=1 • https://www.kingsfund.org.uk/sites/default/files/field/field_publication_file/integrated-care-summary-chris-ham-sep11.pdf • https://www.integration.samhsa.gov/about-us/what-is-integrated-care • https://www.integration.samhsa.gov/about-us/CIHS_Integration_101_FINAL.pdf • https://insights.ovid.com/medical-care/mcar/2011/06/000/understanding-excess-mortality-persons-mental/11/00005650

32. Bibliography • https://thehealthcareblog.com/blog/2014/04/25/the-way-forward-for-integrated-care-what-weve-learned-from-horizontal-and-vertical-integration-of-physicians/ • https://www.cherokeehealth.com/patient-services/adult-primary-behavioral-care • https://www.ruralhealthinfo.org/toolkits/services-integration/2/primary-care-behavioral-health • https://www.healthviewx.com/fqhc-statistics-growth-region-performance-and-revenue-federally-qualified-health-centers-across-usa/