Verena Roberts, Ph.D. Integrated Care Psychologist Elizabeth Lowdermilk, M.D., Psychiatrist

1. Session #B2b Friday, October 11, 2013 Navigating the Clinical Barriers in the Management of Severely and Persistently Mentally Ill Patients Collaborative Family Healthcare Association 15th Annual Conference October 10-12, 2013 Broomfield, Colorado U.S.A. Verena Roberts, Ph.D. Integrated Care Psychologist Elizabeth Lowdermilk, M.D., Psychiatrist Elaine Hess, Ph.D., Post-Doctoral Fellow

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

3. Objectives • 1) Attendees will learn about the current state of integrated care at Denver Health, an FQHC • 2) Attendees will identify and learn about barriers to successful integrated care, including the treatment of the severely and persistently mentally ill patients • 3) Attendees will be able to form ideas and develop a framework around how to enhance collaborative patient care and move current integrated behavioral health approaches to the next level • 4) Attendees will leave with concrete ideas beyond the basic model on how to integrate specific practice options at their own site

4. Learning Assessment Audience Question & Answer We will provide time for questions and in depth-discussion at the end of the session, but please feel free to ask some questions as they come up.

5. DH intro Denver Health – Overview CHS

6. Clinic make up • Eastside Clinic is a federally qualified community health center which provides services for low income patients in central Denver. • Services include: • Primary care/medical • Integrated BH • Integrated pharmacy services • Navigators – self-management goal setting and f/u / in-between care services

7. Clinic make up cont’d • The patients seen: • low income (97% are <200% of the federal poverty level), uninsured or on public insurance (25% Medicare, 32% Medicaid, 32% CICP, 8% DFAP) • are mostly under-represented racial/ethnic minorities (41% African American, 34% Hispanic/Latino)

8. Managing SPMI patients – current status at Denver Health Basic model (How we started) • BHC (FT Psychologist and PT psych. Student) • 2 scheduled 30 min. behavioral health appointments per session (for further evals, tx) • Allows for overbooks for pt. with high follow-up needs • Scheduled and unscheduled (warm-handoffs) integrated visits with PCPs • Identifying patients: • By PCPs during visits • BHCs would also scan provider schedules and discuss possible same-day referrals in mini huddles with PCP • PT Psychiatrist & PT psychiatry resident • 1 pm session a week in clinic • 3-4 40 min. scheduled appointments (3 + 1 OVBK) • E-mail/phone consults about patients - ongoing

9. Managing SPMI patients – current status at Denver Health – cont’d • Clarification of Roles: BHC vs. Psychiatrist • Dx clarification • Appropriately triage/refer or f/u with “high-risk” patients • some case management as related to managing such patients (incl. 3 calls and a letter if pts no-show for f/u) • Treatment (4-6 sessions ideally max.) • Delegation of services for higher level care to: • Psychiatry • Linked to psychiatrist via e-mail or appt. (1-3 visits) • Routine or Crisis evals • Ability to overbook urgent med evals (1 per week) • Urgent phone calls/pager for instant med changes/start via psychiatyr consult and PCP (who starts med) • Linkage to outside tx – referral heavy

10. Managing SPMI patients – current status at Denver Health – cont’d • Summary of key points of basic model at Denver Health • utilizing a step-wise approach • BHC acts as “gate keeper” to psychiatry as well as has ability to “instantly” connect patient with psychiatry to initiate med changes, etc. • Model heavily relied on: • Provider referrals to BH • fact that patients ideally have an outside specialty network of BH services available to them • in case of need for intensive counseling • continued medication management • ongoing crises.

11. Identified difficulties in the management of SPMI to date • SPMI/unable or unwilling to go to specialty MH for variety of reasons as simple as • vicinity/location, transportation issues, mistrust of MH • Chaotic lives • Multiple ongoing crises • PHQ-9/GAD-7 tracking/general screening • may never show improved scores because of ongoing situational stressors

12. Identified difficulties in the management ofSPMI to date (cont’d) • Other Issues: • Safety (lack of time for f/u or no timely f/u with specialty MH due to month long waiting lists or cumbersome appointment access) • Psychosis (lack of insight) • High substance use issues • Basic needs: housing, food security • Questions raised: • How do we ensure continuation of care? • Who tracks high risk patients in terms of f/u outside of system? • Or return visits in our system? • Original model calls for BHCs not to have a case load. How does managing such patients fit with this or not?

13. Identified difficulties in the managementof SPMI to date (cont.’d) • What is lacking in the current/basic model: • care coordination in general • coordination with probation officers • more frequent visits if needed • time for phone calls, education re: case conceptualization w/ PCP • drop in patients who urgently present to clinic (but are not “hospitalizable”) and need psych med adjustments or urgent intervention • System problems • Little MHCD access • % Eastside patients seen by BHC • 32% CICP, 32% Medicaid, 25% Medicare, 8% DFAP, 3% Other • ES has 7027 pts., BHC saw/ had involvement with 595 unique pts (8.5% of total)

14. Identified difficulties in the management of SPMI to date • No MH access on CICP • Patients “kicked” out of specialty care for non-adherence or threats • Low staff to high patient ratio • Cannot see patients 1x week • We see 1x month at most (occasionally with ICVs 2x)

15. Lessons from Other Systems • Management of SPMI in other integrated behavioral health systems: • Access Community Health Center (Madison, WI) • St. Charles Health System (Oregon) • Cherokee Health Systems (Tennessee) • IMPACT Model Khatri, Perry & Wallace (2008) Unützer et al (2001) Personal communication, Robin Henderson, PsyD, St. Charles Health System Personal communication, Neftali Serrano PsyD & Meghan Fondow, PhD, Access Community Health Centers

16. Challenges in Other • Already over-taxed primary care providers struggle to manage SPMI on their panels • Specialty systems are either limited or non-existent • For un- or under-insured • Inability to bill mental health codes in community health • Too few prescribers specializing in psychiatry

17. Creative Solutions from Other Systems • Stepped care approach • Disease management • IMPACT: emphasizes depression • E.g., any new anti-depressant starts • Utilize a care manager • Preferably with mental health background • Risk stratify care • Targeted interventions

18. Creative Solutions from Other • Mental health day treatment program • Include on-site primary care services 1-2 days/week • Complex treatment team meetings • Troubleshoot barriers for complex patients • Process improvement • Telehealth for integrated psychiatrist • Flexible access crucial for those in crisis • In-house 340B pharmacy w/ federal drug pricing

19. It’s All About the Data • Create registries to track highest acuity patients • Track percentage of mental health burden on PCP’s panel • Ensure not overwhelming particular providers • Track outcomes • Functional and symptom improvement • Assess degree of integration • E.g. Atlas of Integrated Behavioral Health Care Quality Measures • http://integrationacademy.ahrq.gov/

20. Changing Policy • Ensure MH billing can occur in primary care setting • Pay flat rates for specialty providers • Spend 1 day/wk at FQHC • Colorado’s SHAPE initiative—global payment model for integration • Sustaining Healthcare Across Integrated Primary Care Efforts • Rocky Mountain Health Plans • Oregon

21. Model Adjustments • We have adjusted our model to address several key areas • Use of modified registry • Risk Stratification • Flexible Access

22. Model Adjustments – Modified Registry • Priority Level System • Addresses patients with acute safety issues or significant psychosis • Pts ranked 1-4 based on our clinical evaluation • BHC caseload = 3s and 4s • Priority 4: expectation is weekly contact, typically near need for hospitalization • Priority 3: expectation is monthly contact, and follow up on no shows/ lack of engagement

23. Model Adjustments – Risk Stratification • Identification of patients using data systems – Who do we not know about and need to? • Psych hospital/ ER DC list • BHCs intervene on those who’s follow up is with the PCP • Assess current clinical status, knowledge of medication changes, ability to get meds, follow up care & barriers; link to RN/ pharmacy/ navigator as needed • Being done by navigators for medical DCs • We have repeatedly found that specific people with some MH knowledge are needed to do this type of work for the BH population • Intend to propose BH specific navigators

24. Model Adjustments – Risk Stratification • Identification of patients using data systems (cont) • Daily List • Patients with visits scheduled that day • MH Flag • Tier 3 & 4 (CMMI tiering intervention) • BHCs are asked to: • Review the list daily and ID pts that they will try to meet with • Known patients who need follow up • Screen unknown patients for MH needs • It remains to be seen if we are identifying the “right” patients

25. Model Adjustments • Identification of patients using data systems (cont) • The trials and tribulations of screening • Large population • Can we address all the need we find? • How much time will we spend screening/ how many patients will we ID who actually are appropriate for BHC services • Who should do the screening? • Two clinic pilots – tried to incorporate screening into the general clinic process using navigators and HCPs have failed • We have temporarily settled on the BHCs screening the Tier 3 & 4 patients • Screen for depression, anxiety, PTSD, bipolar & substance abuse • Will take time to screen this population • Hope in the future to use BH specific navigators in this role

26. Model Adjustments – Risk Stratification • High Risk Case Conference • CMMI intervention • Identifies patients at the clinic/ PCP level • By diagnosis data (DRG) & utilization • 4 Current Clinic Pilots to ID the best model • One theme so far has been that a lot of the changes made to plans of care involve significant SW and BH involvement

27. Model Adjustments– Flexible Access • Drop in access – Psychiatry & BHC • Successfully pilot at one clinic – one half day a week • Addresses high no show rate • Patient Centered - allows for care at the time the patient needs it most • Has sig. increased the number of patients actually seen by psychiatry

28. Future Directions • Tighter coordination of services • SW, navigator role, pharmacy • Better utilizing specific skill sets • Broadening walk-in access • Identification of patient preference for treatment modalities • Telephonic interventions • Groups • Brief therapy • Identification of the “right” group of patients to outreach • Better coordination with and flow between specialty MHCs

29. Questions & Discussion

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