Integrated Care at The Providence Center

2014

Presented by:

Nelly Burdette, PsyD

Director of Integrated Care

The Providence Center

Rhode Island’s largest community mental health organization with an annual budget of $42 million.

In 2013, we served 12,777 people with services provided statewide through 14 service locations in Providence, Burrillville, Cranston, Pawtucket, and Warwick, and 13 client residences in Providence.

5 main service divisions

Adult (SPMI and Health Home) Child and Family Wellness, Employment and

Education Residential Services Crisis Care

Background

TPC’s main administrative offices and adult outpatient services on North Main Street in Providence.

TPC Demographics Gender

54% Male 46% Female

Age 0-3: 1% 4-8: 5% 9-12: 5% 13-18: 12% 19-34: 21% 35-50: 29% 51-64: 22% 65+: 5%

Race and Ethnicity White: 43% Latino: 21% Other/Unknown: 18% Black: 13% Native American: 3% Asian: 2%

Primary Reimbursement Medicaid UBH: 19% Medicaid NHP: 17% Medicare: 14% Medicaid: 16% BCBS: 5% Uninsured: 4% Private: 2%

TPC Primary Diagnoses

Most common across TPC (n=7501)

Depression:26% Adjustment D/o: 11% Schizophrenia: 10% Mood Disorder: 9% ADHD: 8%

Most common across Health Home (n=1878)

Schizophrenia 33% Depression: 27% Bipolar: 13% Mood Disorder: 12% Adjustment D/o: 7%

CY2013 - CSP Health Home Target Conditions

Diabetes10%

Hypertension17%

Hypercholesterolemi

a12%

HeartDisease2%

Hepatitis5%

ObesityOverWeight12%

Asthma10%

SeizureDisorder2%

LeadPoison0%

TraumaticBrainInjur

y1%

Arthritis8%

Hyperlipidemia1%

ThyroidDisease3%

SleepApnea3%

Fibromyalga2%

CVA0%

GERD5%

ChronicBackPain7%

CMHC and FQHCCollaboration

Models

Behavioral Health embedded in medical

Primary care embedded in

behavioral health

Medical nurse care managers within

CMHC(SAMHSA

PBHCI Grant)

Psychologist within FQHC

FQHC embedded within CMHC

Health Home Team withinFQHC

Goals of models

Behavioral Health within Primary Care Setting

Increase awareness of behavioral health care issues for both

provider and patient

Increase access to behavioral health

screening and intervention

Improve chronic disease management

Behavioral health within PC Part-time psychologist at largest PCHC site Specially trained in integrated care within a primary care setting Referrals comprised of a combination of traditional mental health and chronic disease lifestyle managementModel based on 30-minute triage/CBT interventions averaging 3-6 visits per patient, mostly triage and referral

Behavioral health within PC

Providence Community Health Centers at Prairie Avenue Collaboration

Outpatient child and adult practice embedded

within PCHC with bilingual therapist and

bilingual child/adult psychiatrist

New Health Home currently piloting

Diagnostic Rankings

Top three behavioral health diagnoses within FQHC (PCHC @ Prairie)

Male & Female > 18 y/o

1. Depressive Disorder NOS

2. Recurrent Depression

3. Anxiety Disorder NOSMale & Female > 18 y/o

1. Diabetes, Type 2

2. Hyperlipidemia

3. Hypertension

Top three physical health diagnoses within embedded medical center of CMHC (PCHC @ NM)

Goals of models

Primary Care within Mental Health Setting

Improve morbidity and mortality of consumers with

mental illness and addictions

Decrease barriers to access to physical health care for

consumers with behavioral health issues

Improve health literacy for both providers and

clients

Primary care in behavioral health

Providence Community Health Centers at North Main Street

Opened June 2011

“We are partners in health.”

“We treat complex patients

who have complex problems,

many of whom have not sought

health care for a long time. I

talk with my patients about

about understanding what they

have to do to get healthy and

how I can support them.”

-Dr. Tariq Malik, M.D., M.P.H., primary care physician at Providence Community Health Centers at North Main

Personal trainers who are also trained case managers

Individualized fitness and healthy lifestyle assessment performed by the health mentor for every participant

Fitness plan, including eating, exercise, and health promotion

Weekly individual meetings with a health mentor to participate in fitness activities from walking to gym attendance

• Assistance with access to fitness resources

•Opportunities for group exercise and healthy eating education

Primary care in behavioral health SAMHSA funded PBHCI Grant

Awarded in 2010, 4 year grant

Emphasis placed on embedding medical nurse care managers in Home Health SPMI Teams

Education and triage related to management of chronic disease, greater access to primary care

PHQ9, AUDIT, Stanford Self-Efficacy, Self-Rated Abilities for Health Practices and SF-36 administered

Baseline, then every 3 months until one year completion, physical health measures including, BMI, Weight Loss, Blood Pressure, HbA1c, HDL, LDL and Triglycerides

PBHCI ResultsHospitalization Utilization

Psych hospitalization and psych ER use significantly decreased Medical hospitalizations and medical ER visits increased. All types of hospitalizations showed a net decrease (156 days less

net)

Psych Hosp (n=132): 428 days to 256 days

Med Hosp (n=132): 105 days to 146 days

SU Hosp (n=133): 49 days to 24 days

Psych ER (n=134): 72 times to 33 times

Med ER (n=134): 135 times to 196 times

SU ER (n=130): 14 times to 3 times

Cost Savings (n=350)

Psych Hospitalization 428 days to 256 days =

$122,120 savingsNational average $710 per day2

Psych ER 72 times to 33 times =

$27,300 savings National average $700 per day1

SU Hospitalization 49 days to 24 days =

$24,250 savingsNational average $970 per day2

TOTAL $173,670 savings for 350

individuals designated as SPMI

Self-Efficacy (Stanford) Clients belief that they can communicate with physicians,

manage disease in general, manage symptoms of disease, increase nutritional abilities, improve psychological well-being has significantly improved over one year with nurse care coordination.

PBHCI Results

Communicate with physicians From 7.67 to 7.98 (p=.050)

Manage disease in general From 6.51 to 6.76 (p=.052)

Manage symptoms From 5.61 to 5.92 (p=.033)

Nutrition abilities From 17.87 to 18.97 (p=.012)

Psychological Well-being From 14.65 to 16.10 (p=.003)

Total self-efficacy From 62.74 to 65.39 (p=.038)

Health practices From 19.93 to 21.22 (p<.001)

Physical Health Measures Statistically significant improvements over the course of one

year in the below lab values Drawbacks: lab data difficult to obtain and as a result n quite small

PBHCI Results

HgbA1c (n=35 to 13 to 14): 9.4 to 8.7 to 7.6 (p=.032)

TC (n=78 to 26 to 23): 231 to 205 to 199 (p<.001)

LDL (n=58 to 18 to 18): 154 to 123 to 128 (p<.001)

Triglycerides (n=56 to 21 to 26): 300 to 306 to 248 (p=.017)

BP Systolic (n=56 to 41 to 47): 126.55 to 123.32 to 124.3 (p<.001)

BP Diastolic (n=56 to 41 to 47): 80.5 to 78 to 79.4 (p<.001)

Waist Circumference in cm (249 to 163 to 193):

116 to 114 to 113 (p<.001)

Subjective Health (SF-36) Every aspect of health perceived to have statistically significantly

improved over the course of the year, except bodily pain and health perception.

PBHCI Results

General MH 54.77 to 61.82 (p<.001)

Physical Functioning 58.57 to 66.69 (p<.001)

Role Limitations (MH) 44.1 to 57.8 (p<.001)

Role Limitations (PH) 51.32 to 60.19 (p=.027)

Social Functioning 61.11 to 70.04 (p<.001)

Vitality 42.8 to 48.62 (p=.001)

PBHCI Results

If alcohol screening (AUDIT) initially at-risk (>8) AT BASELINE, there was a statistically significant decrease in risk after one year of nurse care management participation

• Mean scores from 15.35 to 9.43 to 9.65. This is a significant decrease at p<.001. (n=40 to 23 to 20)

If depression screening (PHQ-9) initially in the moderate range (>10) AT BASELINE (n=158), there was a statistically significant reduction over the course of one year.

• Mean: 16.15 to 12.17 to 10.72 (p<.001)

Weight change descriptives for BMI>30 at baseline:

PBHCI Results: BMI

6 Months 12 Months

Lost weight 78 (49%) 101 (54%)

No change 19 (12%) 22 (12%)

Gained weight 62 (39%) 64 (34%)

Lost 5% weight 33 (21%) 48 (26%)

Lost <5%/Gained <5% 109 (69%) 108 (58%)

Gained 5% weight 17 (11%) 31 (17%)

BMI (200 to 152 to 186): 38.5 to 37.1 to 36.9 (p=.003)

Integrated care coordinator meets with SPMI (Health Home) patient a few minutes prior to physician entering the room to: assist pt in focusing on the top 3 issues he/she would like

addressed today review logistics of PC: prepare pt about length of appt, any

longer than anticipated wait times, etc. review pt’s mood, new stressors and any emotional issues that

could be impacting physical health

At the same time, physician reviews an interagency form: includes pt’s mental health diagnoses, psychiatric medications

and any relevant notes from mental health team

Health Literacy: Before the Medical Visit

Integrated care coordinator stays with pt for the length of exam to: be a witness to the points of difficulty between pt

and physician provide support to the physician should the pt

experience difficulty communicating provide support to the pt should pt experience

difficulty understanding medical concepts or recommendations

Health Literacy: During the Medical Visit

Health Literacy: After the medical visit

Bottom Line

Integrated care must be infused into the core mission, values and commitment of an organization to be successful.

There is no right way to integrate, but there are known strategies that are evidence-based

Addressing the integrated care needs of the SPMI population is a challenge, but is no longer optional.

Citations

1. Stranges, E. (Thomson Reuters), Levit, K. (Thomson Reuters), Stocks, C. (Agency for Healthcare Research and Quality) and Santora, P. (Substance Abuse and Mental Health Services Administration). State Variation in Inpatient Hospitalizations for Mental Health and Substance Abuse Conditions, 20022008. HCUP Statistical Brief #117. June 2011. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb117.pdf

2. Russo, C. A. (Thomson Healthcare), Hambrick, M. M. (AHRQ), and Owens, P. L. (AHRQ). Hospital Stays Related to Depression, 2005. HCUP Statistical Brief #40. November 2007. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb40.pdf

Contact Information

Nelly Burdette, PsyDDirector of Integrated Care

The Providence Center530 North Main St

Providence, RI 02904

Direct Office: 401/415-8820Email: nburdette@provctr.org