Behavioral and Primary Healthcare Integration

1. Behavioral and Primary Healthcare Integration

2. Overview • 4 year SAMHSA/PBHCI demonstration grant • Navos is 1of 94 grantees across the country and 1 of 3 here in Washington State • Our goal is to develop a model that produces positive outcomes and is financially sustainable • Partnership model with Public Health—Seattle & King County as our primary care partner • Developing a health home for the SMI population served at Navos • One stop shopping • Integrated Team • Collaborative Care Model • Resources • AIMS Center • Dale Jarvis • CIHS

3. Our Model • Partnership with an FQHC having a shared mission • Full scope primary care services operating as part of a collaborative care team with behavioral health clinicians • On-site and operating 4 days per week • Staffing • Nurse Care Manager • Family Practice Physician • Medical Assistants • Peer Specialist • On-site lab and pharmacy • Wellness Program • Smoking Cessation • Exercise • Nutrition • Stress Reduction

4. Shared Reception

5. Floor Plan

6. 1st Year • Establish the partnership • Launch clinic operations • Develop relationships between primary care and behavioral health staff • Develop opportunities for collaboration

7. Clients • Unduplicated users 372 • Referral source • HEART (Adult Outpatient)……..……………………………… 63% • PACT (Program for Assertive Community Treatment)…….. 17% • ECS (Expanded Community Services)………..………….……… 9% • Older Adult……………………………………………….….…. 3% • COD………………………………………………………………. 4% • DV………………………………………………………………..... 2% • Other…………………………………………………………….. . 2%

8. Unduplicated Users

9. Baseline Outcomes • Fasting Plasma Glucose • < 100 56% • > 100 44% • Blood Pressure • Normal 28% • Pre-hypertensive 51% • Hypertensive 21% • BMI • < 25 18% • 25-29.99 26% • > 30 56% • LDL • < 130 75% • > 130 25% • Tobacco users 64% • Stable housing 56%

10. Social/Emotional Health Measures

11. Health Integration Project INDIVIDUAL WELLNESS REPORT Click and use dropdown ê ê Name_PH ID: Normal Navos__TRAC IDs: Caution Status: At Risk 0 Prescriber: No Rating Case Manager_RU: No. of Assessments = 2 6-Month 12-Month 18-Month 24-Month 30-Month 36-Month 48-Month Baseline Reassessment Reassessment Reassessment Reassessment Reassessment Reassessment Reassessment Interview Date 7/8/2012 2/4/2013 Date Blood Drawn 8/15/2012 Lungs Breath CO (0-6) -0.01 -0.01 -0.01 -0.01 -0.01 -0.01 -0.01 -0.01 BMI (18-24) 21.1 21.7 0 0 0 0 0 0 Weight Weight kg 77 79 0 0 0 0 0 0 Height cm 191 191 0 0 0 0 0 0 Systolic BP (90-140) 102 102 0 0 0 0 0 0 Blood Pressure Diastolic BP (60-90) 68 62 0 0 0 0 0 0 Glucose (70-99) 0 97 0 0 0 0 0 0 Blood Sugar Category Hemoglobin A1C (4.0-5.6) 0 0 0 0 0 0 0 0 Total Cholesterol (125-200) 0 175 0 0 0 0 0 0 LDL Cholesterol (20-129) 0 97 0 0 0 0 0 0 Heart Health HDL Cholesterol (40+) 0 59 0 0 0 0 0 0 Triglycerides (30-149) 0 94 0 0 0 0 0 0 Perception of Functioning in everyday life 4 4 0 0 0 0 0 0 No serious psychological distress 2 1 0 0 0 0 0 0 Were socially connected 5 4 0 0 0 0 0 0 Stable place to live in the community Yes Yes 0 0 0 0 0 0 Client Wellness Goal(s): Client Mental Health Goal(s): Action Step(s): Client Signature: ________________________________________ Staff Signature: ________________________________________ Date: ____________ Individual Wellness Report

12. 2nd Year • Develop robust Wellness Program that is data driven and evaluated and supports clients in adopting healthy behaviors and managing their chronic illnesses (quit smoking, exercise and nutrition) • Further develop our model of care in this (reverse integration) setting that is consistent with the elements of a Patient-Centered Health Home • Develop and implement a Collaborative Care Model and culture that produces positive outcomes

13. Patient-Centered Health Home Model Psychiatry Care Management Housing Primary Care Chemical Dependency Supported Employment Therapy Wellness Groups Peer Support Domestic Violence

14. Elements of a Patient-Centered Health Home • Empanelment • Continuous Team-based Healing Relationships • Patient Centered Interactions • Engaged Leadership • Quality Improvement Strategies • Enhanced Access • Care Coordination • Organized Evidence-Based Care

15. Empanelment • Assign all patients to a provider panel • Assess practice supply and demand and balance patient/client load accordingly • Use panel data to proactively track patients by disease status, risk status, or self- management status

16. Continuous Team-Based Healing Relationships • Care delivery teams that are accountable for the patient/client population/panel • Clients are linked to a care team • Assure that clients are able to see their provider or care team whenever possible

17. Patient-Centered Interactions • Respect for client and family values and expressed needs • Clients encouraged to expand their role in decision making, health related behaviors, and self –management • Communication in a culturally appropriate manner and in a language and at a level that the patient understands • Self-management support at every visit through goal setting and action planning • Obtain feedback from clients/families and use this information for quality improvement

18. Engaged Leadership • Visible and sustained leadership to lead cultural change • Ensure that PCHH transformation has the time and resources needed to be successful • Build practice values into staff hiring and training

19. Quality Improvement Strategies • Choose and use a formal model for quality improvement • Establish and monitor metrics to evaluate improvement efforts and ensure that all staff members understand metrics for success • Ensure that clients, families, providers, and care team members are involved in quality improvement activities • Optimize the use of health information technology

20. Enhanced Access • 24/7 continuous access to care team by phone, email, or in person visits • Scheduling options that are patient-family centered and accessible to all clients • Help clients attain and understand health insurance coverage

21. Care Coordination • Link clients with community resources to respond to social service needs • Integrate behavioral health and specialty care into care delivery through co-location or referral arrangements • Track and support patients when they obtain services outside of the practice • Follow up with patients within a few days of an emergency room visit or hospital discharge • Communicate test results and care plans to patients

22. Organized Evidence-Based Care • Use planned care according to patient needs • Identify high risk patients and insure that they are receiving appropriate care and case management services • Use point of care reminders based on clinical guidelines • Enable planned interactions with patients by making up-to-date information available to providers and the care team prior to the visit

23. Collaborative Care Pilot • Team Care structure and process using Care Managers and involving both behavioral health and primary care • Treat to Target using patient registry • Trauma Informed Care

24. Outcome Measures • Hypertension (Systolic) • Diabetes (HbA1c) • Hyperlipidemia (LDL) • Depression (PHQ9) • Trauma (PC-PTSD) • Tobacco use (CO level) • Patient voice • Housing

25. Process • Patient Registry • Development of Team Care structure and approach • Development of administrative and medical flow • Staff engagement and ‘buy in’ • 12 month pilot with a July, 2013 launch

26. Goals • Establish ‘where we are’ with the addition of the collaborative care model • Establish a culture that embraces the ‘Treat to Target’ philosophy • Sustain Trauma Informed Care in all the work we do • Continue our efforts to strengthen, support, foster and sustain a strong relationship with our primary care partner • Positive outcomes for those we serve…’Clients Get Better’!

27. BE BETTER THAN OUR BEST!

28. Questions?