Idalia Massa, Ph.D. S handra Brown- Levey , Ph.D. Primary Care Psychology Fellows

1. Session #G3a October 5, 2012 A state-based initiative to learn what it takes to create and deliver whole person care: Early lessons from Advancing Care Together Idalia Massa, Ph.D. Shandra Brown-Levey, Ph.D. Primary Care Psychology Fellows Collaborative Family Healthcare Association 14th Annual Conference October 4-6, 2012 Austin, Texas U.S.A.

2. Faculty Disclosure I/We have not had any relevant financial relationships during the past 12 months.

3. Objectives • Describe how ACT is organized and designed, including the role and objectives of the steering committee, program office, evaluation team, and the 11 innovation sites. • Summarize the aims and methodology of the ACT learning evaluation. • Discuss ACT’s key next steps, including its operational timeline and plan for dissemination of results.

4. What is ACT? Advancing Care Together (ACT) is a four-year program sponsored by the Colorado Health Foundation. Dynamic collaboration by the behavioral health, substance use, and primary care communities to take action together to discover practical ways to integrate care for people whose health problems and health care needs span physical, emotional, and behavioral domains. ACT funds a portfolio of 11 demonstration projects that aspire to achieve and extend the principles of the patient-centered medical home to integrate mental health, substance use, behavior change, and primary care services. The ACT portfolio is made up of primary care practices and community mental health centers in Colorado servicing diverse geographic areas and employing a range of care delivery models.

5. ACT Governance • Funded by The Colorado Health Foundation • Steering Committee - national and local experts • Mary Jane England, MD — Chair (Massachusetts) • Rosalynn Carter — Honorary Chair (Georgia) • Carl Bell, MD (Illinois) • George DelGrosso, MA (Colorado) • Frank V. deGruy, MD, MSFM (Colorado) • Tillman Farley, MD (Colorado) • Marjie Grazi Harbrecht, MD (Colorado) • Michael Hogan, PhD (New York) • Roger Kathol, MD (Minnesota) • Kelly Kelleher, MD, MPH (Ohio) • Jeannie Ritter (Colorado) • Jeffrey Samet, MD, MA, MPH (Massachusetts) • Edie Sonn, MPP (Colorado) • Marshall Thomas, MD (Colorado) • Nancy Valentine, PhD (Pennsylvania) • Program Office - led by Dr. Larry Green and Maribel Cifuentes • Evaluation Team - led by Dr. Deborah Cohen (OHSU) • 11 Innovation Sites

6. ACT Goals

7. Program Timeline Feb 14, 2011 Call for Proposals releasedSept 1, 2011 Projects beginSept, 2011 First Innovators MeetingSept, 2012 Second Innovators MeetingSept, 2013 Third Innovators MeetingAugust, 2014 Final Innovators MeetingAugust 31, 2014 Projects End

8. ACT Portfolio: 11 Innovation Sites

10. ACT Evaluation Research Questions • What are the interventions implemented by ACT sites? • How do clinics implement the ACT interventions? • What factors facilitate or impede implementation in clinical settings? • What role does teamwork, information exchange, and collaboration play in implementation?

11. ACT Evaluation Research Questions • How does implementation of the ACT intervention impact: • (a) patient’s reported health behaviors and quality of life? • (b) practice level teamwork and communication?, and • (c) practice delivery of disease prevention and chronic disease care • What is the cost of implementing ACT interventions? • How does implementation of the ACT interventions impact service utilization in and outside of the practice?

12. Evaluation: Mixed-Methods

13. Year 1: Early Lessons Learned • Learning how to integrate better • Developing core team with capacity and resilience • Changing culture and identity at the individual, relational and organizational levels • Developing into sustainable integrated clinics

14. Core team capacity, resilience & adaptability • Identifying people who ‘fit’ the new mission and vision • Managing turnover • Developing resilience and adaptability

15. Core team capacity, resilience & adaptability We are looking for a person who has passion for health care reform and the courage to adapt to change. We are looking for the team traits that lend to collaboration, creativity and innovation. We live in a culture of change so we are frequently in an identity crisis. As we evolve team care, our roles are being redefined. This will just add another dimension to that shift. We need to understand each other’s worlds and the respective challenges and needs…We attempted to engage our second BHP in helping write policy and procedure. In addition, we asked for feedback that would define roles and outline mutual responsibilities and accountabilities. Hopefully our next BHP will be more engaged. I plan to have regular meetings with the new BHP to facilitate communication and maintain direction. Working in the provider room should help immensely.

16. Culture and identity change Culture Change • IT • Space for teamwork and collaboration • Creating a culture for learning Identity Change • Shifting how I see myself professionally and how I see myself in relationship with the professional I work with

17. Information Technology Now gentle reader, lest you ask "what has this to do with integration" know this - despite the fact that we have a psychologist in house and I can call him at will and discuss cases, we remain siloed in electronic information exchange, still grasping in the dark too often when treating the comorbid behavioral and physical illness.  We are working toward direct data entry by the patient, instant tabulation of screening tool scores, printed suggestions handed to patients advising treatment, with a coordinated team to coach and facilitate the transition to psychological care from the exam room. Yet the reality is, we did not envision VPN Cisco licenses tapping out, or data center switches reaching capacity, or vendor boundaries with SQL database interoperability when we deployed. The truth is no IT is state of the art for addressing these cutting edge innovations (which are still 20 years behind every other industry). 

18. Creating space for teamwork In order to do integrated care, you need a strong team that knows one another, understands what each person brings to the team in knowledge and position, and can communicate freely when needed. Regulations pull us back to siloed care, billing and funding structures produce barriers to integration, and our own professional training and development pull us towards the known, the comfortable, and the well trodden. In short, we are constantly swimming upstream to do integrated care. Because these forces are powerful and the work is challenging there are two aspects of team building that I believe are essential to genuine movement. The first piece of team building is to help people understand each other’s roles and positions and to have a sense of who knows what and how to use that information and knowledge to function as a team moving in one direction. The second piece is that to function like a team, you have to know each other as people. We have to share food, stories, and get to know our unique personalities.

19. Culture and identity change I’ve spoken today with a psychologist based at an internal medicine clinic in our system who is available and eager to help with integrated care visits, but feels under-utilized. This morning she had 2 scheduled patients and as of 9 am has not had a referral from a clinician. Yesterday, there were 3 scheduled 45-minute visits and no integrated care referrals. I realize that there are several ways to increase integration that are relatively simple and are already being done elsewhere in the system. At another clinic, the psychologist creates a list pulled from the EMR of the day's primary care patients with any ICD-9 psychiatric diagnosis in the past, a list of physical comoribidities, and when and who their appointment is with. This person then talks to the providers about who she should try and see that day. She has 2 scheduled 30 minute visits in the am, and 2 in the pm, and averages 8-13 visits a day including the other integrated visits.

20. Culture and identify shift We are working on outlining what our best practices are going to look like -- , how to do warm hand-offs, what to discuss in huddles. We need to define our processes.  We are meeting to determine workflow and to discuss data retrieval. The medical provider and I have continued to develop our relationship and communication, meshing BH and medical needs in this process.  We are both very open and excited which makes this process work…We are working through our own barriers.  I was hesitant in the beginning and really took a back seat to integration because I had the perception that no one knew what this was going to look like, so who was I to believe that I knew.  So I just sat back and observed, was more passive.  Now after hearing others’ struggles, I feel strengthened to educate my coworkers on what it is I have done for the past 10 years in the MH world. I have stepped forward and began to voice my opinion more, and it is very welcomed.  

21. Final thoughts on lessons learned • The devil is in the details • Sharing patient records (e.g., EHR) • Workflows • Defining roles • Address issues of cultural differences between BHP and PCP • Cultural and Identity changes • Etcetera • Importance of creating a space for reflection • Using of data and information to develop more effective and efficient processes • Engaging practice members and patients in a new model of care

22. Conclusions • Vision for the Organization • Engaging practice member and patients in a new model of care • Data Management for Patients and for Outcomes • Marketing • Billing

23. For More Information www.advancingcaretogether.org Maribel Cifuentes, RNACT Deputy Director303.724.9772Maribel.Cifuentes@ucdenver.edu Department of Family MedicineUniversity of Colorado DenverMail Stop F496, Academic Office 112631 East 17th AvenueAurora, Colorado 80045

24. Session Evaluation Please complete and return theevaluation form to the classroom monitor before leaving this session. Thank you!