PATIENT CENTERED MEDICAL HOME PROJECT- INTEGRATED BEHAVIORAL HEALTH SYSTEMS Bill McFeature, Ph.D....

PATIENT CENTERED MEDICAL HOME PROJECT- INTEGRATED BEHAVIORAL HEALTH SYSTEMS

Bill McFeature, Ph.D. Director of Integrative Behavioral Health Care Services

Southwest Virginia Community Health Systems, Incorporated

Collaborative Family Healthcare Association Annual ConferenceOctober 10-12, Denver, Colorado U.S.A.

Oct 12 session

HEALTH HOMES FOR ENROLLEES WITH CHRONIC CO MORBID CONDITIONS Section 2703 of the Affordable Healthcare Act

allows States to elect this option under theMedicaid State Plan. This provision is an opportunity for States to address the need and support for the enhanced integration and coordination of primary care, behavioral health, dental, and specialty mental health and substance use, and long term services for persons across the lifespan with chronic illness.

CMS –MEDICAID PCMH DEMONSTRATION PROJECT- 2012-2013

CMS -Advance Primary Care Workgroup ( meaningful use measures)

JCAHO Accredited -seeking NCQA Virginia Community Healthcare Association PCMH Collaboration Project Virginia Community Healthcare Foundation Grant- $175,000.

SVCHS PERFORMANCE IMPROVEMENT TEAM

PI Leadership Team meets monthly : 1. Medical Director . Dr. Kerry Moore 2. Behavioral Health Director 3. Quality Care Analyst/Nursing – Jill Talbert 4. TI Director – Tim Lamie 5. Finance/Contracts Director- Brenda

Harris

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NCQA-PCMH PROJECT- LEVEL 3

PATIENT CENTERED MEDICAL HOME GOALS 1. Improve Access/Care Coordination 2. Improve Health Outcomes(PCP-BHC) 3. Cost –Effectiveness (decrease in ER Visits and Medical Care Utilization) with patients associated chronic co-morbid conditions.

SVCHS PCMH PROJECT-LEVEL 3

SVCHS, Inc operates five FQHC’s in extreme Southwest Virginia (Bristol, Meadowview, Saltville, Tazewell, and Troutdale) with a PCP-BHC ratio of 3:1. within each center.

SVCHS implemented the Behavioral Health Consultation Model of Care in 2004 – best Integrated BH practice within primary care.

NCQA-PCMH PROCESS LEVEL 3

- Coordinated Care between PCP-BHCPCMH 1: Access – Medicaid Plan/Self Pay Pts.

Patient receives immediate (1- 3 days) access to a PCP (medical care visit) which will allow the provision of same-day appointments for both a medical care appointment and behavioral health visit (15 min or 30 min) with the BHC.

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NCQA-PCMH PROCESS LEVEL 3

PCMH 1: Electronic Access – Meaningful UseA computer system with access to: eCW

1. Practice Management System (Chronic sx’s)2. Electronic Health Record3. Web Patient Portal4. Access to Pharmacy Registry5. Billing System- Carved Out BH

Reimbursement Rates- NPI Facility #

NCQA-PCMH PROCESS LEVEL 3

PCMH 1: Continuity – Six Panelized/Managed Care Medicaid Contracts, Medicare, Commercial, and Self Pay.

PCP’s panelized to follow co-morbid chronic conditions (Diabetes, Cardiovascular, Asthma/COPD, Depression/Anxiety, and Substance Use Disorders).

NCQA-PCMH PROCESS LEVEL 3

PCMH: 1 Medical Home Responsibilities:Care Coordinator leads morning Huddle MeetingsCare Coordinator will monitor the percentage of co-morbid chronic patients example- (diabetic with associated depression) with high frequency of medical visits, ER visits, hospital stays, and non-compliance to treatment.

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NCQA-PMCH PROCESS LEVEL 3

PCMH 1: Culturally Appropriate Services ---HispanicSouthwest Virginia reflects a significant percentage of Hispanic migrant workers receiving both medical and brief behavioral health services receiving an interpreter.

NCQA-PCMH PROJECT –LEVEL 3

UDS/HEDIS and CCNV-PCMH Vertical Integration Depression and

Substance Use Practice – Extracted Integrative Care Data

PCMH 1: Primary Care Team Approach-Front Desk- (Patient Registration)Health Status Examination (Wt, Ht, BMI) Pain Scale, PHQ-2, and AUDIT-C)If positive PHQ-2-referred to BHC.

If positive for AUDIT-C-referred to BHC

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NCQA-PCMH PROJECT –LEVEL 3

Horizontal Integration- PCP-BHC Coordinated Care -

PCMH 2: Management of Patient Population1. Care Coordinator/Huddle meetings -30 min- each morning.2. Screen and monitor both general patient population (80%) and high risk chronic conditioned patients-- 2 or more chronic conditions (20%) – CCNV Extracted Data

NCQA-PCMH PROJECT –LEVEL 3

PCMH 2: Clinical Data- Integrated Behavioral Health -eCW-Smart Forms (Diabetic(A1c), CAD (BP and Lipids), Tobacco Use and Dependency Practice Guidelines, Chronic Pain Practice Guidelines, Depression Practice Guidelines, and AUDIT-C.

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NCQA-PCMH PROJECT – LEVEL 3

PCMH 2: Comprehensive Health Assessment -Patient -Self Management Skills/HealthLiteracy- Primary Care Philosophy-PCP-BHCObjective: Taking control of your health is the best way to maintain a healthy lifestyle, by working with your primary care team, you can take control of your body to improve your health and live a better life.

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NCQA-PCMH PROJECT-LEVEL 3

PCMH 2: Population Management –Integrated Behavioral Health Services- Preventive Care and Chronic Care Monitoring:PCP –Diagnostic Impression-- warm hand off or referred into BHC schedule:

Streamlined Scheduling to BHC-30 min visit Patient seen in exam room for 15 min visit.

NCQA-PCMH PROJECT- LEVEL 3

PCMH 3: Patient Integrated Care Plan – PC Team - AMA Ethical Standards and Practice

Evidenced–Based PCBH Practices for High Risk Co-morbid Chronic Patient Population using Brief CBT, Solution- Focused, and BH Consultation.Universal Standard-Behavioral Health(PHQ-2 and PHQ-9) and Alcohol and Drug Screens(AUDIT-C) at each visit.

NCQA-PCMH PROJECT –LEVEL 3

PCMH 4: Care Coordination-High Risk PCBH Groups -Care Coordinator works closely with the multidisciplinary healthcare team( MD, FNP, PA, BHC, and supportive nursing staff(LP/MA) in the primary care setting focusing on health coaching and coordination of care for high-risk, chronically ill patients and those with co-morbid conditions.

NCQA-PCMH PROJECT- LEVEL 3

PCMH 4: Psychotropic Medication Management- Continuum of Care -1. PCP-BHC Coordinated Care –General2. Contract with UVA TelePsychiatry - for CMI patients, stable.3. Triage with local CSB’s for specialty mental health services, CMI, unstable.

NCQA-PCMH PROJECT –LEVEL 3

PCMH 4: Provide Self–Care and Access to Specialty Mental Health Services for Major Psychiatric Disordered Patients, Unstable

WE ARE WORKING ON IT………offering OfficeSpace, donuts, we lure CSB clinical case

managers to the clinic.

NCQA-PCMH PROJECT- LEVEL 3

PCMH 5: Extracted Integrated BH Data –Utilizing Smart Forms that capture Integrated Care Data (co morbid medical and behavioral health conditions).

Extracted Integrative Care Data in coordination

with CCNV- governing body oversees credentialing, MCO contracts, and performance measures analysis.

NCQA-PCMH PROJECT- LEVEL 3

PCMH 6: Measure and Improved PCP-BHC Coordinated Care Performance Data -1. Psych Dx rate of General PatientPopulation - 20%.2. Patient Cycle Time (<45-50 min for PCP’sdistribution)- quick access for BHC services.3. Behavioral Health Program Analysis (130- 160 Monthly BHC Encounter Rate using ACG.

ACG SYSTEM : ILLNESS BURDEN AND PRICING OF BUNDLED SERVICE PRODUCTThe ACG is a packaged software that uses the diagnosis codes and pharmacy data, to categorize patients by level of sickness. For instance, patient diagnosed with Diabetes Mellitus ( A1c- 8.1), uncontrolled, Hypertension, BMI of 39, and (LPN)- PHQ-2- yes, referred to BHC- PHQ-9- based on 2 visits-score of 17 to determine level of patient complexity determininga value score- 2014- integrative care data.

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Questions?

THANK YOU!