CJ Peek, PhD

1. NC Center of Excellence for Integrated Care: Advocates for Practice ChangeRegina Dickens, Ed.D., LCSWMaria Dover, MS, LMFT

2. What is our history? CJ Peek, PhD

3. The North Carolina Center of Excellence for Integrated Care builds on the work of a Foundation-sponsored program, The ICARE Partnership, which pioneered the integration of care in primary care practices between 2006 and 2010 through a broad inter-agency, multi-disciplinary partnership.

4. Rene Descarte (1641) Philosopher & mathematician Commonly given credit for establishing separate domains for the physical and mental-- and the philosophical basis for the "mind-body split". CJ Peek, PhD

5. “Integrated Care” is an effort to better match or blend clinical services to the realities that patients and their cliniciansface daily.” A legacy of separate and parallel systems Behavioral Health Care Medical Care • A forced choice between: • Two kinds of problems • Two kinds of clinicians • Two kinds of clinics • Two kinds of treatments • Two kinds of insurance CJ Peek, PhD

6. Why the system doesn’t work…

7. Common clinical presentations don’t stay neatly in those medical or BH boxes • Behavioral / psychosocial is part of medical care • 70% of all PC visits have psychosocial drivers • 50% of all BH care is done by PCP’s • 67% of all psychoactive drugs prescribed by PCP’s • Referral to BH/CD hard to navigate; often doesn’t connect CJ Peek, PhD

8. Untreated Depression = More Healthcare Use • Depressed patients use 3 times more healthcare services • Depressed patients have 7 times more emergency visits • Depression is associated with longer hospital stays

9. Trauma associated with Intoxicant Use: • In 2005, up to 60% of US trauma center patients tested positive for one or more intoxicants • Of these 1 in 4 had a second drug and alcohol related injury in the same year. Maier, 2009

10. NC primary care providers (PCPs) and behavioral health providers agree that: • There is difficulty finding a referral for publicly or uninsured patients • There are few opportunities to develop relationships with primary care providers • There is a huge benefit to community psychiatrists being available for consultation and establishing a working relationship with the PCPs.

11. One Solution is Integrated Primary Care Integrated primary care is a service that combines medical and behavioral health services to more fully address the spectrum of problems that patients bring to their primary medical care providers. It allows patients to feel that, for almost any problem, they have come to the right place. Alexander Blount A definition…

12. A look at integrated care…

13. Patient Centered Care includes: INTERNAL COLLABORATION CLINICAL - quality care - patient driven OPERATIONAL FINANCIAL • systems • organization • process improvement - coding - billing - reimbursement

14. ON-SITE Integrated Care Team NP’s PA’s Physician Receptionists Patients Nurses and medical assistants Behavioral Health Therapists Medical Records Psychiatrists All supported by common chart, documentation standards, billing procedures, and clinic management system

15. Integrated Care Program Behavioral Health Services integrated with Primary Health Care: Nurse screens clients at establish care and annual appointments Physician sees client and validates screening • Screening • Assessment • Brief supportive counseling • Therapy • Case management • Medication monitoring • Coordinated team care Physician introduces client and therapist Physician and therapist provide team approach for coordinated care

16. Integrated Care Works • Randomized Control Trials demonstrate: • More effective medication treatment • Reduced depression severity • Improved general health status • Decreased disability • Better occupational function • Improved patient satisfaction • Cost-effectiveness

17. Our Current Projects

18. CHIPRA: A Quality Demonstration Grant The CHIPRA statute mandates the ‘experimentation’ and ‘evaluation’ofseveral promising ideas related to improving the quality of children’s healthcare. Slide by Stacy Warren

19. Needs of America’s Children American children experience worse health and higher levels of mortality than do children from most other developed nations and receive recommended care only 42% of the time UNICEF, The State of World’s Children, 2009 (visited April 10,2009 Mangione-Smith R, Decristofaro A, Setodji C, KeeseyJl, Adams The Quality of Care Received by Children and Adolescents in the US. Pediatric Academy Societies, E-PAS2006:59:4500.1 Slide by Stacy Warren

20. Medicaid Enrollees on the Rise In 2009, 60 million people were on Medicaid and over half of them were under 18. 1 in every 4 American children are on Medicaid Approximately 31% of NC children are on Medicaid www.statehealthfacts.org 2008-2009 Slide by Stacy Warren

21. Center for Medicare and Medicaid Services (CMS) is committed to demonstrating improvement in Medicaid/CHIP systems through: The synthesis of data and activities from diverse Medicaid/CHIP systems Providing Technical Assistance to States Tracking improvement using metrics This includes addressing health care disparities, long term health care needs supports and services and builds on the synergy and coordination of efforts with public health agencies, education and mental health care systems to improve the health care outcomes for children. Slide by Stacy Warren

22. CHIPRA Categories: A - Experiment with and evaluate the use of new and existing measures of quality for children B – promote the use of health information technology (HIT) for the delivery of care for children C – evaluate provider-based models to improve the delivery of care D – demonstrate the impact of model pediatric EHRs (electronic health records) E – creating targeted models to demonstrate their impact on health, quality and cost.

23. Category A Core Measures • NC will use its Community Care infrastructure to implement and evaluate the use of the new set of 24 quality measures identified by AHRQ and CMS. • NC will expand upon the current data collection system to incorporate the core set of children’s health measures and will work with local practices on the implementation, feedback and the meaningful use of the quality information for improvements in performance.

24. CHIPRA Category A Measures Update • Categories for the 24 Core Measures • Prenatal, Immunizations, Screening, Well Child Visits, Dental, Availability, Upper respiratory, ED, Inpatient Safety, Asthma, ADHD, Mental Health, Diabetes, Family Experience • Unique to North Carolina • EPSDT Report Card, Dental Varnishing, MCHAT, Adolescent and School Age Screening, Obesity, Foster Care Kids Linked to a Medical Home • Reporting Timeline • Reporting a subset of the measures annually to CMS as of 12/2011 and quarterly to practices starting 6/2011

25. 24 Core Measures Working with DMA, SCHS and Vital Records to capture the remaining eight measures. We’re attempting to report on an additional 8 of the 24 core measures using paid claims. We’re currently reporting on 8 of the 24 core measures requested by CMS through the IC. Three stages of progress…. Potential roadblocks… • The identification of current sources for PICU/NICU data • CAHPS is only reported once every three years • Transition from old to new systems makes data collection problematic..immunizations and birth certificate data • It’s difficult to identify CHIP recipients in the claims system

26. New Measures • EPSDT Report Card • Lead, vision, well visits, developmental screening, autism • Dental Varnishing • Pediatric preventive measure from IC • 99420 Reports X 3 • MCHAT, School Age Screen, Adolescent Screen • Obesity • Follow up for clients with an obesity diagnosis • Foster Care • Kids Linked to a Medical Home

27. Quality Improvement • Quality Improvement will focus on…

28. Reporting • Reportingto CMS through CHIP Annual Reporting Template (CARTS) system • Reporting to practices through Provider Portal

29. Slide by Stacy Warren Category C--CHIPRA‘Connect’ NC will strengthen the medical home for children and youth with special health care needs (CYSHCN) by testing and evaluating provider-led, community-based models that will identify, treat and coordinate the care of CYSHCN, particularly children with developmental, behavioral and /or mental health disorders

30. CHIPRA Connect • Demonstrate a provider-based model of care for CYSHCN by testing and evaluating provider-led, community-based models • Practices will utilize the AAP Mental Health Toolkit • Emphasis on linkages and reliable communication systems

31. CHIPRA CONNECT PROJECT 2015 Obesity 2014 Oral Health Risk Stratification Tool Medical Home 2013 Mental Health Toolkit Obesity Learning Collaborative for Cohort II begins Oral Health 2012 Mental Health Toolkit 2011 PCP Pre-Work

32. Cohort 1 Participants Community Care of the Sandhills • Dr. MasoudAhdieh • ABC Pediatrics • Sandhills Pediatrics • Harnett County Health Department AccessCare • Goldsboro Pediatrics Community Care Plan of Eastern Carolina • Washington Pediatrics • Surf Pediatrics Northwest Community Care Network • Surry County Health and Nutrition Center • Kids Count Pediatrics • Westgate Pediatrics • Robinhood Pediatrics

33. Each strategy will propel quality improvement both independently and in concert with the other strategies Slide by Stacy Warren EHR supports Medical Home implement quality care Measures inform and evaluate impact of EHR D Pediatric Electronic Health Record Medical Homes will drive service-oriented, quality EHR development Measures enable ongoing, flexible tracking of Medical Home Impact EHR enables will enable efficiencies and timely tracking and meaningful use of quality measures A Quality Measures Medical Homes provide data on feasibility, cost and value of measures C Medical Home

34. Category D-Pediatric Electronic Health Record • Existing EHR systems often do not optimally support the provision of health care to children. • The goal of Category D is to develop a model EHR Format for children, demonstrate that it can be readily used, and package it in a way that facilitates broad incorporation into EHR systems. • NC, through its Community Care program, will work closely with the NC Regional Extension Center (REC) in the implementation of the model Electronic Health Record for Children (EHR). • PEHR consultants in all 14 Networks will work with providers/medical homes interested in implementing the model PEHR.

35. How do we implement practice change?

36. Steps to Practice Change • Identify and Convene stakeholder groups to: • Design/update needs assessments for each targeted practice group • Identify current and emerging evidenced based best practice models • Set quality assurance/ model fidelity measures for targeted practice areas • Monitor the process • Identify ways to improve family involvement in healthcare

37. Steps for Practice Change (continued) • Establish learning collaboratives • Establish a cadre of experts to deliver training and TA • Establish Evaluation Protocols with outside Evaluator to monitor Center of Excellence goals and outcomes • Establish procedures to monitor lessons learned and adjust for needed changes on a quarterly basis

38. How Can Families Be More Involved?

39. The Medical Home Family Index • Purpose: to better understand how families of children and youth with special healthcare needs view the services they receive from their PCP. • As a practice moves to become a ‘Medical Home’ it is important to capture how the family perceives those efforts and where there is room for improvement. • Ex. of question: I am asked by our PCP how my child’s condition affects our family (impact on siblings, the time my child’s care takes, lost sleep, extra expenses, etc). • Survey is provided in both English and Spanish.

40. CHIPRA TEAM • Dr. Marian Earls, Physician Champion • Stacy Warren, Project Director • stacy.warren@dhhs.org; (919) 715-1088 • Janie Shivar, Category A Clinical Coordinator • janie.shivar@ncfahp.org; (919) 863-0063 • Marla Satterfield, CHIPRA Connect Pediatric Program Manager • marla.satterfield@ncfahp.org; (919) 863-0063 • Maria Dover, CHIPRA Connect Clinical Coordinator • maria.dover@ncfahp.org; (919) 863-0063 • Kern Eason, Category D Pediatric EHR Consultant • keason@n3cn.org; (919) 745-2426