Session #D3 October 28, 20113:30 PM Behavioral Health/Pediatric Primary Care Integration at Geisinger: Year 1 Implementation & Evaluation Shelley Hosterman, PhD Paul Kettlewell, PhD Christine Chew, PhD Tawnya Meadows, PhD Collaborative Family Healthcare Association 13th Annual Conference October 27-29, 2011 Philadelphia, Pennsylvania U.S.A.
Faculty Disclosure We have not had any relevant financial relationships during the past 12 months.
Need/Practice Gap & Supporting Resources • Parents often bring their children to primary care physicians first (Smith, Rost, & Kashner, 1995) • 15% to 21% of primary care visits are for behavioral health concerns (Kelleher, Childs, Wasserman, McInerny, Nutting, Gardner, 1997; Lavigne, Gibbons, Arend, Rosenbaum, Binns, Christoffel, 1999; Williams, Klinepeter, Palmes et al., 2004). • During 50% to 80% of child health care visits, parents or physicians raise concerns of behavioral or psychosocial issues (Cassidy & Jellinek 1998; Fries et al., 1993; Sharp, Pantell, Murphy, & Lewis, 1992).
Need/Practice Gap & Supporting Resources Problems with seeking behavioral health services from PCP: • Increased number of medical visits • Increased time spent with the physician • Lost revenue if a patient takes more time than scheduled • Lower reimbursement rate for mental health issues • Limited training in mental health treatment (Connor, McLaughlin, Jeffers-Terry, O’Brien, Stille, Young, & Antonelli, 2006; deGruy, 1997; Leaf, Owens, Levelthal, Forsyth, Vaden-Kiernan, Epstein, Riley, & Horwitz, 2004; Strosahl, 2002; Young, Klap, Sherbourne, & Wells, 2001)
Need/Practice Gap & Supporting Resources Problems with seeking behavioral health services from PCP: • Decreased number of patients seen • Increased risk of physician burnout • Unsatisfied patients • Increased impairment in patient health and functioning • Increased use of acute and emergency care (Connor, McLaughlin, Jeffers-Terry, O’Brien, Stille, Young, & Antonelli, 2006; deGruy, 1997; Leaf, Owens, Levelthal, Forsyth, Vaden-Kiernan, Epstein, Riley, & Horwitz, 2004; Strosahl, 2002; Young, Klap, Sherbourne, & Wells, 2001)
Objectives • Understand the collaborative development process with the Geisinger Health Plan & Pediatric Partners • Describe Geisinger’s pilot model • Describe program evaluation plans for this project • Review baseline data for the program
Agenda • Developing the model – Process & Supports • Details of pilot model • Program evaluation & research • Baseline data & future directions
Development: Previous System • Outpatient mental health services, inpatient psychiatric unit, & consultation/liason in major hospital • 3 pediatric psychs, 1 family therapist, 1 psychiatrist, 3 pre-doctoral interns, & 2 postdoc fellows • Serving all children/adolescent in 5 counties, all patients with Geisinger PCPs, specialty patients • Concerns with system: Waitlists, no shows, patient travel, caseloads, problems recruiting psychiatrist
Development: Model Prototype Munroe-Meyer Institute – Inspiration for our model University of Nebraska Medical Center; Omaha, NE http://www.unmc.edu/mmi/behavioral/ Joseph H. Evans, Ph.D. Director, Psychology Department Rachel Valleley, Ph.D. Outreach Behavior Health Clinics Coordinator
Development: Model Prototype • Behavioral health services in primary care • 23 outreach clinics across Nebraska • Reaching underserved, rural populations • Co-located & collaborative clinics • Interns/postdocs trained in the setting • Education for PCPs • Frequent contacts regarding referrals • Research & program evaluation • Promising outcomes – Discussed later
Development: Our System Geisinger Health System - • Integrated health network • Serves 43 counties; 20,000 sq miles; 2.6 million people • Nearly 60 community practice sites across the state • System-wide electronic medical record • Geisinger Health Plan – Among nation’s largest rural HMOs (270,000 members)
Development: Marketing Change Step 1: Approached psychiatry administration (10/09) • Response – Excellent concept, but no way to proceed within budget Step 2a: Presentation at psychiatry grand rounds (2/10) • Response – Excellent concept • Possibility #1 – Private donor looking for a way to support mental health of children/adolescents • 2b: Private meetings & additional presentation to private donor secured substantial gift
Development: Marketing Change Step 3: Presentation to Pediatric Grand Rounds (03/10) • Response – Pediatrics enthused & many requested Step 4: Presentation to Geisinger Health Plan (Spring ‘10) • Summary – Model offers better care, may save money, & carve out model of payment does not make sense • Response – We agree, what should we do? • Key message – They believe is better care & will support if we can break even or save money
Development: GHP Proposal Monthly planning meetings with GHP administration Data review process: • Medical expenses for pediatric patients with ≥1 BH visit double those of comparison patients • Key cost differences: Outpatient, pharmacy, & ED • Potential for cost off-set? Outcome: GHP funded pilot project & program evaluation
Development: GHP Proposal Proposal objectives: • Improve quality of behavioral health care • Reduce medical expenses & utilization of patients with BH concerns • Increase physician, parent, & patient satisfaction with service model& delivery • Expand PCP knowledge of BH assessment & intervention • Improve access, adherence, efficiency, & integrity of BH services & intervention
Development: Task Force • Key stakeholders • Review problems & solutions in our system & state • Information gathering & review of other models • Focus on partnership, collaboration, & consultation to help children & adolescents • Electronic survey of primary care providers
Development: PCP Survey Most common problems Most want training/assistance ADHD (45%) Disruptive Behavior (43%) Anxiety (32%) Obesity (29%), Depression (26%) Eating Disorders (26%) • ADHD (77%) • Obesity (72%) • Depression (57%) • Anxiety (47%) • Disruptive Behavior (44%)
Development: PCP Survey Barriers to service: Desired Models: On-site services (76%) Training in assessment & diagnosis (65%) Medication consults (64%) Screening tools (49%) • No local resources (94%) • Getting appt (55%) • Insurance issues (46%) • Travel for families (35%) • No time to address (24%) • No training (20%) • Patient Follow (11%) • No collaboration (11%)
Development: Task Force Follow-up interviews with primary care: • Additional input • Assess site specific enthusiasm, barriers, and % GHP • Identified three sites Presented to CPSL Three goals: • Behavioral health providers on-site in PCP sites • Support PCPs with screening tools & training • Case consultation with child/adolescent psychiatrist
Clinic Structure: Team Planning • Team planning meetings – Psych & PCPs, office staff • Shadowing PCPs • Billing discussions • REACH Institute training – PCPs & Psych’s together • Focus on screening & psychopharm
Clinic Structure: Services Report templates: Concise, completed during visit, structured for brief review Clinician schedules: 1 psychologist + 1 psychology fellow • 75 min evals, 45 min returns • 75% scheduled – Always available to PCP Warm hand-offs& consultations: • Join visits, education, pass patients on, simple recommendations, immediate eval • Tracking details
Clinic Structure: Services Handouts – Common for psychologists & PCPs Crisis evaluations as needed Communication – Medical record & constant contact Ongoing training for PCP’s • Monthly case conferences • Presentations on request Relationship building – Join clinic community
Clinic Structure: Services Common screening tools Anticipate high-volume issues • ADHD evaluations • Weight management • DBC groups Psychiatry consultation – Case review & phone consultation Electronic screening tools – Results directly in medical record
Clinic Structure: Services Brief Case Examples
Program Evaluation: Key Domains • Satisfaction • PCP comfort/knowledge in assessment & intervention • Quality of life • Clinically significant symptoms • Medication use • Utilization data • Clinic efficiency data • Quality of Care v. Practice Standards
Program Evaluation: Tools & Predictions Satisfaction: Pre & Post questionnaires for parents & PCPs Includes: • Convenience, time to first appointment, Stigma/Comfort • Communication with PCP • Perceived Benefit Predict increased satisfaction relative to traditional model Comfort and Knowledge: Physician survey • Pre & post training, pre-integration, & yearly Predict increases across each measurement
Program Evaluation: Tools & Predictions Quality of Life: Peds QL-4 • Pre & post intervention • School questionnaire – attendance, performance • Predict improved QOL & school attendance • Predict match results from other CBT outcome studies Clinical symptoms: Target behavior ratings • 5 point Likert Scale at every session • Dual purpose - research outcomes & tracking treatment goals • Most immediate/likely measure of change • Predict steady reductions across course of treatment
Program Evaluation: Tools & Predictions Medication use • Chart review – Pre and post integration, per diagnosis • Predictions – More appropriate use (sufficient trials, monitoring change, appropriate match to symptoms) Utilization data: Chart Review • # Medical visits: Frequency PCP visits reduced pre v. post • Specialist visits: Frequency reduced pre v. post • Time to first visit – Reduced delay between physician referral & assessment vs. traditional model in our system • Out of network – Pre & post insurance company data. Predict reduced out of network
Program Evaluation: Tools & Predictions Efficiency data • Time study: Pre, yearly, post • Code: Medical, Beh, & Med/Beh visits • Appointment duration: no change on medical appointments, less time on behavioral & med/beh Cost savings & cost effectiveness: Pre, yearly, post • Predict increase in overall clinic revenue, reduced PMPM cost for patients with BH issues Quality of Care • Identify AAP standards of care • Chart review assessing adherence with standards
Time Study Data
Results
2.9% of all patients observed were referred to peds psych 28% of those diagnosed with a psychological disorder were referred to peds psych Referral to Pediatric Psychology
Baseline data: Referrals & Handoffs
Learning Assessment Questions?
Session Evaluation Please complete and return theevaluation form to the classroom monitor before leaving this session. Thank you!
Contact Information Shelley J. Hosterman, PhD sjhosterman@geisinger.edu References available upon request
