CFHA Presentation: Integrating Behavioral Health into an Academic Practice

1. SUSAN C DAY, MD, MPH Director of Quality and Practice Improvement Division of General Internal Medicine University of Pennsylvania CFHA Presentation:Integrating Behavioral Health into an Academic Practice

2. Description of DGIM Practices • 3 Internal medicine practices on UPENN Campus; 1 located in suburbs (not in pilot) • Total IM faculty: approx 30 (including part-time) • Total residents • 104 Categorical and Med-Peds • 22 Primary Care • All 3 practices are NCQA Level 3 recognized; 1 is a participant in SEPA Chronic Care Collaborative • All practices on EPIC, electronic health record

3. Practice Volume Office Visits per year (September 2010- August 2011) • Edward S. Cooper Internal Medicine Associates: 25,601 • PennCare Internal Medicine Associates: 21,559 • Penn Center for Primary Care: 17,298

4. Baseline Behavioral Health Resources • 2 social workers knowledgeable re local resources; help with referrals • Penn Behavioral Health • UPHS does not accept several of major insurers, including medical assistance, except in resident psychiatric practice • Capacity at resident practice limited • Emergency care available through Psychiatric Emergency Center • “Check the back of your card”

5. Goals of Co-location Pilot 1) To provide triage of all patients, regardless of insurance, for short term care when appropriate and link to outside services if needed 2) To improve outcomes in patients with chronic illness where behavioral health issues key (PCMH) 3) To facilitate identification of covered providers for patients with non-UPHS covered mental health services

6. Planning DCPS identified 3 of their top providers for project Beginning with 1 practice, they met with providers, staff, social workers to establish relationship and work flow Rolled out at approx 2 month intervals to the remaining 2 practices

7. Patient Flow: DCPS co-location project No show N=88

8. Summary of 6 month pilot • 406 patients were referred • 140 (36%) could not be contacted after 3 attempts • 266 appointments were made • 88 (33%) no showed • 178 evaluated

9. Insurance Mix

10. Evaluation: Goal #1Provide triage of all patients regardless of insurance • High (33%) no show rate • Disproportionate referral of Medicaid patients • Inability/unwillingness to pay co-pay (only 31% paid co-pay) • Difficulty linking to appropriate behavioral health services • Lack of identified psychiatric back up • Lack of medical assistance providers for ongoing care

11. Evaluation: Goal #2 Improve outcomes in patients with chronic illness where behavioral health issues key Depression, anxiety felt to be cause for failure to advance care in patients with chronic medical disease HOWEVER Providers tended to refer patients with pre-existing psychiatric disease, not patients with chronic disease needing counseling to improve adherence

12. Pre-existing medical and psychiatric diagnosis and meds

13. Goal #3: Facilitate identification of covered behavioral health providers Providers greatly appreciated being able to contact behavioral health provider for advice and ability to provide a personal referral to patients Most providers (90%) either did not have a list of behavioral health providers they used for referrals or were looking for additional referral sources

14. Faculty Survey

15. Provider Survey, cont’d

16. Positive Outcomes Good will of DCPS providers and willingness to see all patients were very positively received New connections made for future referrals were established Experience was gained in terms of setting up a system for referral and triage Real time needs assessment uncovered significant psychiatric comorbidity and need for psychiatric back-up and consultation

17. Lessons learned Unmet need within our practices is for patients with medical assistance/under-insured Business model unsustainable without either subsidy/grant or limited patient selection Building relationships takes time (and work) Need to define expectations/model for ongoing collaborations