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Navos is a pivotal participant in the 4-year SAMHSA/PBHCI demonstration grant, focusing on integrating behavioral and primary healthcare to improve outcomes for individuals with serious mental illness (SMI). As one of three grantees in Washington State, our goal is to create a sustainable model in collaboration with Public Health—Seattle & King County. We offer full-spectrum primary care services through a dedicated team, utilizing a collaborative care model. Our focus includes wellness programs, on-site services, and supportive resources for healthier living.
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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
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
1st Year • Establish the partnership • Launch clinic operations • Develop relationships between primary care and behavioral health staff • Develop opportunities for collaboration
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%
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%
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
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
Patient-Centered Health Home Model Psychiatry Care Management Housing Primary Care Chemical Dependency Supported Employment Therapy Wellness Groups Peer Support Domestic Violence
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
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
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
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
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
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
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
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
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
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
Outcome Measures • Hypertension (Systolic) • Diabetes (HbA1c) • Hyperlipidemia (LDL) • Depression (PHQ9) • Trauma (PC-PTSD) • Tobacco use (CO level) • Patient voice • Housing
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
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’!
