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2017 Spring Learning Series
Integrating Primary Care into Behavioral Health Settings
Healthier Washington Practice Transformation Support Hub | 2017 Spring Learning Series
The project described was supported by Funding Opportunity Number CMS-1G1-14-001 from the U.S. Department of Health and Human Services, Centers for Medicare &
Medicaid Services. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.
Integrating Primary Care in Behavioral Health Settings
Table of Contents
Unit 1: Foundational Concepts for Integration Objectives…………………………………………………………………………………………. 2
Next Steps – Learning Activities………………………………………………………… 21
Integration Plan Worksheet………………………………………………………………. 22
Identifying Process and Outcome Measures Guide……………………………. 23
Unit 2: Team Roles and Readiness for Integrating Care
Objectives…………………………………………………………………………………………. 26
Next Steps – Learning Activities………………………………………………………… 44
Tasks for Integrated Care in Behavioral Health Settings Worksheet….. 45
Unit 3: Developing Your Clinical Workflow for Integrated Care
Objectives…………………………………………………………………………………………. 47
Next Steps – Learning Activities………………………………………………………… 68
Team Building and Workflow Guide………………………………………………….. 69
Unit 4: Population Management - Using a Registry to Track Outcomes
Objectives…………………………………………………………………………………………. 74
Next Steps – Learning Activities………………………………………………………… 91
Patient Tracking Spreadsheet Practice Case Scenarios………………………. 92
Unit 5: Introduction to Quality Improvement Methods
Objectives…………………………………………………………………………………………. 100
Example 1 – Measuring Blood Pressure…………………………………………….. 104
Example 2 – Measuring BMI in Adolescents………………………………………. 124 Next Steps – Learning Activities………………………………………………………… 147
PDSA Worksheet……………………………………………………………………………….. 148
Laying the FoundationIntegrating Primary Care into Behavioral HealthWebinar 1
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• Learn how to adopt core principles ofintegrated care for behavioral health settings
• Explore opportunities for new roles andresponsibilities for integrating care
• Create workflows and a tracking tool for anintegrated care pilot
• Develop a rapid cycle QI proposal for anoutcome measure your integrated care programis working to improve
Objectives for Learning Series
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Learning Series Structure
•Week 1: Webinar 'Laying the Foundation'•Week 2 (Self-Paced): Integration Plan, Readiness Assessment and Discussion Board
1. FoundationalConcepts forIntegration
•Week 3: Webinar 'Team Roles and Readiness for Integrating Care'•Week 4 (Self-Paced): AIMS Task List and Discussion Board•Week 5 (Self-Paced): AIMS Task List and Discussion Board
2. Team Roles andReadiness for
Integrating Care
•Week 6 : Webinar 'Developing your Clinical Workflow for Integrated Care'•Week 7 (Self-Paced): Develop Screening & Treatment Workflow and Discussion Board•Week 8 (Self-Paced): Develop Screening & Treatment Workflow and Discussion Board
3. DevelopingYour ClinicalWorkflow for
Integrated Care
•Week 9: Webinar 'Using a Registry to Track Outcomes'•Week 10 (Self-Paced): Registry Activity and Discussion Board•Week 11 (Self-Paced): Registry Activity and Discussion Board
4. PopulationManagement:
Using a Registry to Track Outcomes
•Week 12: Webinar 'Introduction to Quality Improvement Methods'•Week 13 (Self-Paced): QI Activity and Discussion Board•Week 14: PDSA Sharing and Facilitated Discussion
5. Introduction toQuality Improvement
Methods
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From: Premature Mortality Among Adults With Schizophrenia in the United StatesJAMA Psychiatry. 2015;72(12):1172-1181. doi:10.1001/jamapsychiatry.2015.1737
• Adult MedicaidBeneficiaries Diagnosedwith Schizophrenia
• 10 Common Causes ofDeath by Age Group(2001-2007)
• Standardized MortalityRatios : 2 to > 10
• No change from 2006NASMHPD report
Why Integrate Care for CBHC clients?
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Most Premature Mortality Due to CVD
• Life expectancy is15 years shorter
• CVD accounts for60% of prematuredeaths amongpersons withserious mentalillnesses
• Every CVD risk factor is more than twice as commonCorrell CU, et al. Psychiatr Serv. 2010 Sep;61(9):892‐8.https://www.cdc.gov/diabetes/data/statistics/2014statisticsreport.htmlhttps://www.cdc.gov/nchs/products/databriefs/db133.htmhttps://www.niddk.nih.gov/health‐information/health‐statistics/Pages/overweight‐obesity‐statistics.aspxhttps://www.cdc.gov/cholesterol/facts.htm
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Health Behavior Interventions1
• Lifestyle modification; 30-40% lose weight
• Smoking cessationpharmacotherapy; 40%quit2
Medical Care Management3
• Health education• Care coordination• Track treatment
Behavioral Health Home4
Evidence-based Interventions
1McGinty EE et al Schizophr Bull. 2016 Jan;42(1):96-124; 2Tsoi DT, et.al. Cochrane Database Syst Rev 2013 Feb 28; 2; 3Druss BG, AN J Psychiatry; 2010; 167(2): 151-159; 4Druss BG, et al. Am J Psychiatry 2017; 174(3): 246-255
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Jha P, et al. N Engl J Med 2013; 368: 341-350
• Overall mortality among smokers(of both sexes) is 3 times as highas those who have never smoked
• Smokers lose, on average, adecade of life
• Cessation before the age of 40reduces risk of death by 90%
Smoking and Mortality
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• Cochrane review—(34 RCTs)• Bupropion
– End of treatment (vs placebo)• 7 trials (n=340)• RR= 3.03 (95% CI= 1.69-5.42)
– 6 months• 5 trials (n= 214)• RR= 2.78 (95% CI = 1.02-7.58)
• Varenicline– End of treatment (vs placebo)
• 2 trials (n=137)• RR= 4.74 (95% CI= 1.34-16.71)
– 6 months• 1 trial (n= 128)• RR= 5.06 (95% CI = 0.67-38.24)
Summary of Evidence: Medication
Tsoi DT, et.al. Cochrane Database Syst Rev 2013 Feb 28; 2: CD007253 Barboza JL et al. Expert Opin Pharmacother. 2016 Aug;17(11):1483-96.
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• Cochrane review (n=34 studies)– Some support for contingency management,
but unclear long-term benefit
• Systematic review of combination treatment2
– 123 RCTs, >60,000 patients– Best evidence for varenicline and behavioral
treatment
Summary of Evidence: Behavioral Interventions
1. Tsoi DT, et.al. Cochrane Database Syst Rev 2013 Feb 28; 2: CD0072532. Windle SB, et al. Am J Prev Med. 2016 Sep 8. pii: S0749-3797(16)30278-1.
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• Longer duration (24weeks)
• Manualized
• Combined educationand activity
• Both nutrition andphysical exercise
• Evidence-based (proveneffective by RCTs)
Behavioral Weight Loss Interventions
Most Likely Effective Less Likely Effective
• Briefer durationinterventions
• General wellness orhealth promotioneducation-only
• Non-intensive,unstructured, or non-manualizedinterventions
Bartels S, et al. SAMHSA-HRSA Center for Integrated Health Solutions, 2012
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• Patient Population– Adults with Severe Mental Illness
• New Team Member Roles– Primary Care Consultants– Primary Care RN Care Managers
• Annual Metabolic Screening
• Diabetes Education and Treatment
• Pay for Performance (Missouri example)– Half of Quality Performance Measures are Medical– Half of Medication Adherence Measures are Medical
Behavioral Health Homes
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• SAMHSA Primary Behavioral Health CareIntegration (PBHCI) Grantees– National Demonstration Program (2009-
present)– 100 CMHCs– 4-year projects– Outcomes1: mean reduction in cholesterol
and LDL
• HOME Study2
– Randomized controlled study (n= 447)– BHH improved quality of care for persons
with SMI and CVD risk factors
Evidence for Behavioral Health Homes
1. Scharf DM, et.al. Psychiatr Serv. 2016 Nov 1;67(11):1226-12322. Druss BG, et al. Am J Psychiatry 2017; 174(3): 246-255;
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Principles for Evidence-Based Integration in Behavioral Health and Primary Care
Team-Based and Client-Centered Primary care and behavioral health providers collaborate effectively, using shared care plans.
Measurement-Based Treatment to Target Measurable treatment goals clearly defined and tracked for every patient. Treatments are actively changed until clinical goals are achieved.
Population-Based A defined group of clients is tracked in a registry so that no one “falls through the cracks.”
Used with permission from the University of Washington AIMS Center
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Client-Centered Team: Behavioral Health Home
PCP
PsychiatristCare
Manager/ Registry
Patient
Mental Health Center
Primary Care
Case Manager
Used with permission from the University of Washington AIMS Center
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KEY= RN= Psychiatrist
Refer to PCP for diabetes
treatment
Check weight, blood pressure, smoking status & order metabolic labs
Yes No
Weigh at next visit
Counsel
Re-evaluate medications
Repeat BP Check BP at next
visit
Yes No Yes No
Offer treatment
NoYes
Yes No
Re-evaluate medications
Measurement-Based Care Workflow Example
A1c > 5.7%
A1c > 6.5%?
BP > 140/90?
Smoker? BMI > 25?
Annual screen
Yes No
Check BP at next
visit
Refer to PCP for
HTN treatment
BP still > 140/90?
Counsel
Screen at next visit
Used with permission from the University of Washington AIMS Center
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Case Number
Active in Care Management
Date Primary Physician RMHC PsychiatristNext Psychiatrist
Appt Date
Standard monitoring labs last done BMI LDL HbA1c
Fasting plasma glucose
Diastolic BP
Next PCP appt
Next case
manager contact due
3/18/2011 Ramirez 5.1.15 6/12/2014 32 152 6.9 121 102 3.12.15 4.1.153/5/2012 No PCP 9/11/20135/15/2014 RHC12/2/2014 Dr Ramirez5/21/2014 Dr. Sanchez 7/17/2014
Dr. Sandival4/19/2012 Dr. Przeniczny5/21/2014 Dr. Simantarkis MISSING6/27/2012 Dr. Carter 11/3/20145/21/2014 MISSING2/23/2011 Dr. Vavilala 7/16/20144/5/2011 Dr. Vavilala 2/25/20148/15/2012 Dr. Girn5/21/2014 NP Snezana MISSING
Population-Based Care: Registry Example
Used with permission from the University of Washington AIMS Center
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Lay the foundation
Plan for practice change
Train team in new roles
Launch new
workflowSustain
Implementation Timeline
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• What are your goals for this program?
• Who will the program serve (target population)
• How will you know the program is working– What process measures?– What outcomes will be tracked, when and how?
• What are some strengths of your organization thatwill support this work?
• What challenges do you anticipate in this work?
Making an Integration Plan
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• Where is your organization now?– Leadership– Behavioral health case managers– Psychiatric prescribers– Others
• Who do you think you still need to convince?
Cultivate Organizational Buy-In
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Maine Health Access Foundation (MeHAF) Self-Assessment
Site Readiness Assessment
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• Engage your core integration team– Weekly meetings
• Complete activities for Unit 1: Lay the Foundation– Develop an integration plan– Cultivate organizational buy-in– Complete a readiness assessment
Next Steps – Learning Activities
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The project described was supported by Funding Opportunity Number CMS-1G1-14-001 from the U.S. Department of Health and
Human Services, Centers for Medicare & Medicaid Services. The contents provided are solely the responsibility of the authors and
do not necessarily represent the official views of HHS or any of its agencies.
Integration Plan
Program Name:
What are your goals (short- and long-term) for this program?
Who will the program serve? Identify a target population.
How will you know the program is working? Process and outcome measures, intervals, and targets.
What will be some of the strengths your organization will bring? What will be some of the challenges?
Used with permission of University of Washington AIMS Center. Originally developed by A. Ratzliff, MD, PhD and J. Unützer, MD, MPH, MA
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The Healthier Washington Practice Transformation
Support Hub
Bi-Directional Integration Spring Learning Series: Behavioral Health Track Measures
Process Measures Choose at least one
Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents
Definition: The percentage of clients 3-17 years of age who had a visit with a PCP and who had evidence of the following during the measurement year: (1) BMI percentile documentation; (2) counseling for nutrition; and (3) counseling for physical activity. Report three separate rates.
Numerator: Clients who had BMI percentile documentation, counseling for nutrition, and counseling for physical activity during the measurement year.
Denominator: Clients age 3-17 years of age with a visit with a PCP in the measurement year.
Exclusion: Clients who were pregnant during the measurement year.
Source: NCQA (HEDIS), NQF 0024, WA State Common Measure Set 2017
Adult Body Mass Index Assessment
Definition: The percentage of clients 18-74 years of age who had an outpatient visit and whose body mass index (BMI) was documented during the measurement year or the year prior to the measurement year.
Numerator: Clients 18-74 years of age with a BMI documented during the measurement year or the year prior to the measurement year.
Denominator: Clients age 18-74 years of age with a visit in the past two years.
Source: NCQA (HEDIS), WA State Common Measure Set 2017
Comprehensive Diabetes Care: HbA1c Testing
Definition: The percentage of clients 18-75 years of age with diabetes (type 1 and type 2) who had an HbA1c test during the measurement year.
Numerator: Clients who had an HbA1c test performed during the measurement year.
Denominator: Clients age 18-75 years of age with a visit in the last year.
Exclusion: Clients who do not have a diagnosis of diabetes in the measurement year, or the year prior to the measurement year or have a diagnosis of gestational diabetes or steroid-induced diabetes.
Source: NCQA (HEDIS), NQF 0057, WA State Common Measure Set 2017
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The Healthier Washington Practice
Transformation Support Hub
Outcome Measures
Choose at least one
Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Poor Control (>9%)
Definition: Percentage of clients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement year.
Numerator: Clients whose most recent HbA1c level (performed during the measurement period) is > 9.0% or is missing a result or the test was not done during the measurement year.
Denominator: Clients 18 - 75 years of age with diabetes with a visit during the measurement year.
Exclusion: Clients who do not have a diagnosis of diabetes in the measurement year, or the year prior to the measurement year or have a diagnosis of gestational diabetes or steroid-induced diabetes.
Source: NCQA (HEDIS), NQF 0059, WA State Common Measure Set 2017
Controlling High Blood Pressure
Definition: The percentage of clients 18 to 85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was controlled during the measurement year.
Numerator: Clients ages 18 to 59 as of the end of the measurement year whose BP was <140/90, ages 60 to 85 as of the end of the measurement year with a diagnosis of diabetes and whose BP was <140/90, or ages 60 to 85 as of the end of the measurement year, not with a diagnosis of diabetes with BP of <140/90.
Denominator: Clients 18-85 years of age with at least one encounter with a hypertension diagnosis on or before the midpoint of the measurement year.
Exclusion: Clients who are diagnosed with End Stage Renal Disease, who were pregnant during the measurement year or who had an encounter in a non-acute inpatient setting during the measurement year.
Source: NCQA (HEDIS), NQF 0018, WA State Common Measure Set 2017
Sources: Washington Common Measure Set:
https://www.hca.wa.gov/assets/program/2016.12.20.Common-Measure-Set-Health-Care-Quality-Cost-Approved.pdf
National Quality Forum:http://www.qualityforum.org/Measures_Reports_Tools.aspx
National Committee for Quality Assurance:http://www.ncqa.org/hedis-quality-measurement/hedis-measures/hedis-2017
The project described was supported by Funding Opportunity Number CMS-1G1-14-001 from the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.
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Team Roles and Readiness for Integrated Care Integrating Primary Care into Behavioral HealthWebinar 2
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Webinar objectives: • Review readiness assessment and integration plan.
Discuss challenges and opportunities forintegration
• Define team member roles and responsibilities forintegrated care in a BHA setting
• Explore opportunities for new roles andresponsibilities in a fully integrated model of care
• Discuss the next steps for team building
Learning activity after webinar:• Complete the task list as a team
Learning Objectives
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• Part of our mission – to care for vulnerablepopulation
• No one else is doing it
• Opportunity for frequent touches
• Possible payoff in overall medical spend
• As well as opportunity for improvement inquality of life for our clientele, before it is toolate!
Improving Health Outcomes in A Seriously Mentally Ill Population
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• Access to staff, resources, funds, andprimary care partners highly variable
• No center in Washington has access to anadequate stream of funding to cover thiscompletely
How To Approach Change in Your Site?
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• How high a priority is this for theorganization?
• Is this a cardinal activity for a communityhealth organization? If not, why not?
• Are there resources that can be shifted, if you“have to?”
Changing Priorities: Easy For Me To Say!
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Client-Centered Team: Behavioral Health Home
PCP
PsychiatristCare
Manager/ Registry
Patient
Mental Health Center
Primary Care
Case Manager
Used with permission from the University of Washington AIMS Center
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• Screening function
• Psychiatrist function
• Care management function
• Registry function
• PCP function
Care Functions
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• Some means of gathering data:– Vital signs– Lab data– Smoking status
• How can you do this?– Medical assistant or nurse in BHA setting– Data from primary care partner– Clipboards
Screening Function
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• Review and interpret physical health data
• Clarify history
• Exam
• Synthesize and plan
• Prescribe (minimize risk)
• Communicate with PCP – form letters?
• Communicate with care management
Psychiatrist Function
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Care Management Functions per Parks
• Care Coordination• Managing Transitions of Care• Health Promotion• Referral to Community Services
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• The place in the system where the client andthe system treating the client are mostimpacted
• Most of the other functions exist in order to getthe care manager where they need to be, whenthey need to be there
The Care Manager Is The Business End of The Stick
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Multiple staff can perform these functions and have different strengths/limitations:
– Behavioral health case managers• Used to coordinating care, interfacing with the
outside world• Less medical background
– Nurses• More medical background• [Sometimes] less comfort with SMI population• More expensive!
– Peers• The benefit of lived experience• Less medical background
How To Deploy Staff To Perform Care Management Functions
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Integration of Care in BH Needs Someone To Drive the Registry
PCP
PsychiatristCare
Manager/ Registry
Patient
Mental Health Center
Primary Care
Case Manager
Used with permission from the University of Washington AIMS Center
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• Permits tracking, treatment to target ofphysical conditions
• Does involve double entry
• Doesn’t have to be impossibly complicated
• Someone has to do it, but it doesn’t have tobe a doctor or a nurse
• Oversight of the registry is different – airtraffic controller function
• A function, not a person
Registry Function
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Registry Example
Used with permission from the University of Washington AIMS Center
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• Medical management• Collaboration with BH team• Teaching, monitoring of patients
• Almost never in your organization• Often requires a lot of effort on care manager’s
side to get what is needed from the PCP
PCP Function
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• Medical assistants are less expensive than nurses [thoughturn over faster]
• Funding workarounds
• Partner with an FQHC
• Choose a small group to cut your teeth on
• Don’t overreach and try to cure the $3M man
• Get data – improvements can be invisible to the naked eyeand staff can become demoralized
• Do things in groups – if the staff is asking EVERYONE aboutsmoking, it gets to be automatic
• Proximity matters – if people rub elbows, not so manymeetings need to be scheduled
• Phone calls are quicker than trips
Brainstorming About Ways to Coordinate Care on a Budget
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• Identify and engage clients
• Primary care assessment, planning andtreatment
• Treatment outcomes: track and adjusttreatment
• Provide effective program support
Team Building Worksheets
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Addressing The Tasks in a BH Setting: Assessing Gaps
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• Complete the AIMS Center Integration Task List
Next Steps – Learning Activities
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Tasks for Integrated Primary Care in Mental Health Settings Are we doing this task now? If yes, Who is doing it? If no, who should do this
task? How should this task be
tracked? Screening Yes No Screen for Medical Problems : Office-Based Measurement (e.g. Weight, BMI, Blood pressure)
Screen for Medical Problems : Lab Measurements (e.g. HbA1C; Lipids) Screen for Health Behavior Risk: smoking, substance use, physical activity Assess where patient receives primary care Follow-up of Screening and Treatment Yes No Diagnose Medical Conditions that Need Treatment Client Education about treatment options for chronic medical conditions Prescribe Medications for Chronic Medical conditions Health Behavior Change Counseling: Smoking Cessation Health Behavior Change Counseling: Weight Management/Nutrition Health Behavior Change Counseling: Increase Physical Activity/Exercise Facilitate Referral and Coordination with Specialty Medical Care Identify Clients who Need Medical Care Management Care Coordination Yes No Obtain ROI to share information with PCP Share clinical information with PCP Track Treatment Outcomes Yes No Track Treatment Engagement & Adherence of Medical Care using Registry Reach out to Clients who are Non-adherent or Disengaged from Medical Care
Track Office-Based Measurement (e.g. Weight, BP) Track Lab Measurements (e.g. HbA1C) Track Behavioral Health Measures Track Medication Side Effects & Concerns Track Outcome of Referrals Assess Need for Changes in Treatment Facilitate Changes in Treatment if Not Improving Conduct Caseload-Focused Primary Care Consultation
Used with permission from University of Washington AIMS Center
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Develop Your Clinical Workflow for Integrated Care Integrating Primary Care into Behavioral HealthWebinar 3
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Webinar objectives: • Review the task summary worksheets and discuss
the challenges that arose for teams.• Understand how to translate new tasks for physical
health monitoring into an integrated care workflow.• Apply this workflow redesign process to
participants’ clinical teams workflow.
Learning activity after webinar:• Complete the workflow guide and develop a
process map.
Learning Objectives
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Task Summary Worksheet Review
• Tasks for screening for chronic medicalconditions and monitoring outcomes
• Supports reporting of Medicaid TransformationProject demonstration outcomes
• Breaks down into phases of clinical care, eachwith a workflow
• Goal is to identify– Tasks that are not currently being done– Tasks that need improvement
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• Common understanding of work
• Focus on the process not the people
• Clear visual definition of current workflow
• Illuminate improvement opportunities byclarifying unnecessary work
• Identify metrics to measure improvement
Process Mapping
45
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• Who is involved?
• How is it done?
• What are the steps?
– Identify current workflow
– Design future state (ideal) workflow
• What is the final product?
Workflow Redesign 101
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The Process Map Tells the Story
• Sequence of tasks
• Involvement of people
• Use of documents, systems and othersources of information
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Components of a Process Map
Start & EndPoint
Action StepsDecisions
Direction flow
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Checkpoint: Current Workflow
• Think about your currentworkflow around metabolicmonitoring…
• How well are prescribersdoing this now?
• What are the majorchallenges to trackingthese outcomes in a timelyway—AND adjustingtreatment?
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• Process mapping “ideal” testable workflow
• Identify simple metrics
– To see if things are heading in the right direction
– Identify potential unintended consequences
• Future state mapping ends with an action plan/tasklist with three components:
– Task
– Responsible Party
– Timeline
Development of the Future State
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• Behavioral Health Agency that has served childrenand adults for past 25 years– 6,000 patients a year
• Staffing– 3 FT psychiatric prescribers– Clinic nurse– Case management service– 2 clinic admins
• No primary care partner per se, but 35% of patientsseen in a family medicine practice in thecommunity
Example CBHC
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Integration Plan Example
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Task List Example
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Task List Example (Cont’d)
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• Decision: Track BMI in high-risk population– new prescriptions of atypical
antipsychotic medication, or– patients new to us on atypical
antipsychotic medication
• Follow ADA-APA guidelines for monitoring.
Building Workflow for Tracking
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ADA-APA workgroup. Diabetes Care 2004; 27: 596-601.
BL 4 wks
8 wks
12 wks
q 3mo
q 1Yr
PMH / Family Hx X XWeight (BMI) X X X X XWaist Circumference X X
Blood Pressure X X XFasting glucose X X XFasting lipids X X X
ADA-APA Guidelines
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• Patients on SGA are high risk and metabolicoutcomes should be monitored
• How identify a subgroup to track?– Review of administrative data– Review of prescriber caseloads– Start with new SGA prescriptions– Start with new clients
Deciding on the Starting Point
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How Do We Screen
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How Do We Screen (Cont’d)
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How Does Prescriber Use and Respond to Information?
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Tracking Treatment Outcomes
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Care Coordination and Treatment
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Big Picture: How Do We Act on Data to Improve Care?
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• Complete the Workflow Guide• Create a Process Map of your clinical Screening
and Treatment Workflow
Next Steps – Learning Activities
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The project described was supported by Funding Opportunity Number CMS‐1G1‐14‐001 from the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.
Used with permission from University of Washington AIMS Center
Agency Name: Date: Screening WorkflowTasks for Integrated Care in Community Behavioral Health Settings
WHO Name, Discipline
HOW Process (Including Hand‐offs) & communication methods (e.g., telephone, mail)
WHEN In terms of patient flow and time constraints
WHERE Clinic? Partner agency? External referral?
Screen for Chronic Medical Conditions: Office‐Based Measurement (e.g. Weight, BMI, Blood Pressure)
Screen for Chronic Medical Conditions: Lab Measurements (e.g. HbA1C, Lipids)
Screen for Health Behavior Risk: Smoking, Substance Use, Physical Activity, Nutrition
Verify Where Patient Receives Primary Care
Organization‐Level Changes ☐Staff Hires
☐Staff Training
☐Clinical Supervision
☐Administrative Supervision
☐Other Resources needed:
Notes:
Refer to this completed guide when creating a process map for your clinical workflow.
The project described was supported by Funding Opportunity Number CMS‐1G1‐14‐001 from the U.S. Departmentof Health and Human Services, Centers for Medicare & Medicaid Services. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.
Used with permission from University of Washington AIMS Center
Follow‐Up of Screening: Treatment Workflow Tasks for Integrated Care in Community Behavioral Health Settings
WHO Name, Discipline
HOW Process (Including Hand‐offs) & communication methods (e.g., telephone, mail)
WHEN In terms of patient flow and time constraints
WHERE Clinic? Partner agency? External referral?
Diagnose Medical Conditions that Need Treatment
Client Education about Treatment Options for Chronic Medical Conditions
Prescribe Medications for Chronic Medical Conditions
Health Behavior Change Counseling: Smoking Cessation
Health Behavior Change Counseling: Weight Management/Nutrition
Health Behavior Change Counseling: Increase Physical Activity/Exercise
Identify Clients who Need Medical Care Management
Organization‐Level Changes ☐Staff Hires
☐Staff Training
☐Clinical Supervision
☐Administrative Supervision
☐Other Resources needed:
Notes:
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The project described was supported by Funding Opportunity Number CMS‐1G1‐14‐001 from the U.S. Departmentof Health and Human Services, Centers for Medicare & Medicaid Services. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.
Used with permission from University of Washington AIMS Center
Care Coordination Tasks for Integrated Care in Community Behavioral Health Settings
WHO Name, Discipline
HOW Process (Including Hand‐offs) & communication methods (e.g., telephone, mail)
WHEN In terms of patient flow and time constraints
WHERE Clinic? Partner agency? External referral?
Obtain ROI to Share Information with PCP
Share Clinical Information with PCP
Obtain Medication and Lab Data from PCP and Make Available in BH EMR
Coordinate PCP Appointments (e.g., Patient Reminders, Communication with PCP Office, Prior Authorizations]
Coordinate With Other Providers (e.g., pharmacy, medical equipment, specialty medical care)
Organization‐Level Changes ☐Staff Hires
☐Staff Training
☐Clinical Supervision
☐Administrative Supervision
☐Other Resources needed:
Notes:
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The project described was supported by Funding Opportunity Number CMS‐1G1‐14‐001 from the U.S. Departmentof Health and Human Services, Centers for Medicare & Medicaid Services. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.
Used with permission from University of Washington AIMS Center
Track Treatment Outcomes Tasks for Integrated Care in Community Behavioral Health Settings
WHO Name, Discipline
HOW Process (Including Hand‐offs) & communication methods (e.g., telephone, mail)
WHEN In terms of patient flow and time constraints
WHERE Clinic? Partner agency? External referral?
Track Engagement in Primary Care & Outreach to Those Not Engaged
Track Adherence to Medical Treatment
Track Office‐Based Measurement (e.g. Weight, BP)
Track Lab Measurements (e.g. HbA1C)
Track Behavioral Health Measures
Track Medication Side Effects & Concerns
Track Outcome of Referrals
Assess Need for Changes in Treatment and Facilitate Changes, if Not Improving
Conduct Caseload‐Focused Primary Care Consultation
Organization‐Level Changes ☐Staff Hires
☐Staff Training
☐Clinical Supervision
☐Administrative Supervision
☐Other Resources needed:
Notes:
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Population Management: Using a Registry to Track Outcomes
Integrating Primary Care into Behavioral HealthWebinar 4
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Webinar objectives:
• Understand the principles of population health managementand how they apply to community behavioral healthworkflows
• Understand how to use a registry to provide measurement-based care
• Discuss the pros and cons of different registry options
Learning activity after webinar:
• Practice population health management with a sampleregistry
Learning Objectives
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Principles for Evidence-Based Integration in Behavioral Health and Primary Care
Team-Based and Client-Centered Primary care and behavioral health providers collaborate effectively, using shared care plans.
Measurement-Based Treatment to Target Measurable treatment goals clearly defined and tracked for every patient. Treatments are actively changed until clinical goals are achieved.
Population-Based A defined group of clients is tracked in a registry so that no one “falls through the cracks.”
Used with permission from the University of Washington AIMS Center
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• Population Health– The health outcomes of a group of individuals,
including the distribution of such outcomeswithin the group
• Population Care– Design, delivery, coordination, and payment of
high-quality health care services to manage theTriple Aim for a population using the bestresources available within a health care system
Population Health Management
www.ihi.org
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“Involves the systematic use of symptom rating scales to drive clinical decision making.”
Measurement-Based Care
https://www.thekennedyforum.org/news/measurement-based-care-issue-brief
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• Measurable treatment goals (“targets”) are defined
• Patients monitored using clinical measures orvalidated clinical rating scales (PHQ-9, GAD-7)– Standardized monitoring schedules based on
treatment guidelines
• Results of scales and other patient measurestracked in a registry
• Treatment results regularly evaluated andtreatment is adjusted until target goals achieved
Measurement-Based Care
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• Track population-based care
• Track progress at individual, caseload, andpopulation level
• Facilitate efficient, systematic case review
• Prompt treatment to target
• Provide timely reminders
• Provide decision support
Registry Requirements
Used with permission from the University of Washington AIMS Center
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• Data collection integrated into clinical workflow.Standard protocol for data collection at prescribervisit. Who and where recorded?
– Weight/ BMI– Blood pressure– Labs
• Outside lab results called to attention of prescriberor PCP, as necessary
• During course of treatment, BMI regularly trackedand 12-week labs obtained
Measurement-Based Care in Practice
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• Care team must have readily available data onpatient status and outcomes to drive changesin treatment– In any measurement-based model, it is
difficult to achieve improvement in outcomeswithout regular review of data
• Workflow should prompt this– For example in a Behavioral Health Home,
the PCP consultant uses registry data toprioritize patients for case review andtreatment adjustments
Actionable Data in a Registry
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• When: Weekly, 60-90 minute sessions
• Who: Medical care manager, PCP consultant
• How: in-person or by phone– Registry & EHR must be available to both
• Goal: monitor entire caseload over time– review all patients on caseload in one session– only priority patients over several sessions
Systematic Case/Data Review
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Example: How to Use a RegistryIntegrating Outcomes into the Clinical Workflow
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• Excel Spreadsheet + EHR– AIMS Patient Tracking Template
• Build into EHR or Care Management System– EPIC
• Healthy Planet• Reporting workbench
Examples of Registries
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• Reflect on your experiences tracking behavioralhealth outcomes? What did you use to track?
• EHR?• Web-based population management software?• Excel?
• Reflect on your experiences using a registry fortracking physical health measures?
• Reflect on your experiences using symptom ratingscales? How did you track these at the individual,case and population level?
Checkpoint
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• Many healthcare organizations investing significantresources
• Thus far, few successes, numerous failures, manywar stories
» Epic Healthy Planet» Epic Pre-Healthy Planet» Valant Behavioral Health HER
• Approach with caution!
Registry Functions Built into EHR
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FunctionalityPatient
Tracking Spreadsheet
Customized EMR
Registry
Legal medical record
Used for billing
Tracks progress at individual patient level
Tracks population-based care Varies
Tracks progress at caseload level Varies
Facilitates psychiatric consultation and systematic case review Varies
Prompts treat to target strategies Varies
Provides decision support Varies
Cues Care Manager outreach Varies
Aggregates data across multi-Institutional projects
Comparing Registry Tools
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• 52 y/o man with historyof major depressivedisorder andhypertension
• Lives alone, volunteers atYMCA
• BMI = 33 kg/ m2; BP =153/ 94
• Smokes 1.5 ppd• PHQ-9 = 4
• Eats at KFC most days;6 Dr. Peppers daily
Case Example
• Medications– Mirtazapine 15 mg at
night– Amitriptyline 150 mg
at night– Bupropion SR 100 mg
daily– HCTZ 25 mg daily
• ASA 81 mg daily• Labs
– A1c = 8.5%– TC = 240; HDL = 30
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AIMS Center Patient Tracking Spreadsheet: “Patient Tracking” Tab
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AIMS Center Patient Tracking Spreadsheet: “Caseload Overview” Tab
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• Discuss Registry Options with your IntegrationTeam
• Review Case Example Scenarios
Next Steps – Learning Activities
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Most Important Things to Know About the Patient Tracking Spreadsheet
1. The PRIMARY purpose of the registry is to help you support the clinical work of theteam. The Patient Tracking Spreadsheet is designed to serve YOU. If you feel like you’re serving the registry, something is wrong and we can help. Let us know! We can show you how to use the registry so that it serves you and helps you with your job.
2. The registry works best when you use it every day throughout the day.The registry can help you quickly and easily see who is getting better, who is not, and who needscontact. The registry can only help if you use it every day alongside your electronic health record.
3. The registry helps guide patient contacts.The registry facilitates patient contacts (phone or in person) with a patient by reminding you when afollow-up contact is due.
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Getting Started
The following scenario is designed to help you learn how to use the Patient Tracking Spreadsheet to facilitate management of high-quality evidence-based medical care in a behavioral health setting.
Checklists at the end of each section indicate Patient Tracking Spreadsheet skills learned.
To get started, please open the Patient Tracking Spreadsheet, and make sure you click “Enable Editing” and “Enable Content” in the yellow bar at the top of the page.
This scenario is meant to be used in conjunction with the Patient Tracking Spreadsheet Template Quick Start Guide, which contains further instructions for each column on the spreadsheet.
We recommend that you read each scenario first, and then enter applicable information into the spreadsheet. After you have entered the information, use the checklists at the end of each section to ensure you have included the appropriate pieces of information.
As a team, discuss what steps you would take with the client in each scenario. Remember to think about actionable steps and follow-up with the client and not just entering the data!
Benny, Case #12345
Initial Contact 6/1/2016: Benny is a 52 year-old white male with history of treatment resistant Major Depressive Disorder and hypertension. Benny has lived alone in a subsidized housing apartment complex for the last 15 years, and has been relatively stable. He does not work, but contributes some to the local YMCA as a front-desk greeter three days a week.
Benny likes to watch old reruns of classic black and white TV shows when he’s not at the YMCA. He also smokes about 1.5 packs-per-day (PPD). He primarily eats out fast food from a KFC about a block away, but Ben brings him some fresh food every once in a while to stock in his refrigerator. He drinks about 6 Dr. Peppers a day too. Benny’s BMI is 33 kg/m2.
In May, Benny went to the hospital for some chest pain. A workup at that time ruled out a heart attack, and your team received the discharge paperwork from an overnight stay indicating the ER thought he had anxiety.
Benny has seen Dr. John for his primary care for the past 15 years since his housing stabilized. He usually sees Dr. John about once every 6 months, but missed his last appointment and has not seen Dr. John since he was in the hospital.
Benny saw the psychiatrist, Dr. Speedy and care manager, Kate, to enroll in services on June 1st.
Benny’s medications as of June 1st include: 1. Mirtazapine 15 mg once daily2. Amitriptyline 150 mg once nightly
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3. Bupropion SR 100 mg twice daily4. Hydrochlorothiazide 25 mg once daily5. Daily Aspirin, 81 mg
Practice the Following Registry Skills: □ Enter all possible new patient information fields□ Enter all known contacts and dates□ Enter all known measurements□ Enter the action plan you would take as the care team for Benny
Benny Follow-up Contact 7/20/2016 Benny was admitted again for chest pain and was found to have had a heart attack. Benny’s blood pressure upon discharge on July 10th was 153/94 mm Hg, HbA1c was 8.5%, and his BMI was 33 kg/m2. On discharge, he was prescribed three new medications in addition to his other medications:
1. Metoprolol 50 mg twice daily2. Metformin 500 mg twice daily3. Atorvastatin 20 mg daily
Benny has not gone to see his PCP since you met with him in June.
Registry Skills: □Update contact information□Update care manager contact date□Update measurements□Update and add any new action plans
Benny Care Coordination 7/28/2016 You call Benny and ask if he has scheduled his medical appointment. He lets you know he has an appointment on August 10th! In addition you place a request for his medical records from Dr. John.
Registry Skills: □Update care manager contact date□Update PCP upcoming appointment date□Update and add any new action plans
Benny Follow-up Contact 8/16/2016 Benny is in for an appointment with Dr. Speedy and you have a chance to briefly meet him. Benny saw Dr. John on August 10th and his blood pressure was 138/88. Benny has been taking his medications more consistently, and began an exercise program with approval from Dr. John at the YMCA. He is able to cut back a little more on his smokes with the help of a nicotine patch.
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Registry Skills: □Update care manager, PCP and psychiatrist contact dates□Update measurements□Update and add any new action plans
Case Load Review 11/20/2016 You are reviewing your case load and realizing that Benny’s last PCP appointment was in August 2016 and his PCP asked that he return in 3 months. You follow-up with Benny by phone and make a note that you want to see him the next time he is in to see his psychiatrist.
Registry Skills: □Review the caseload overview page for last contact information and BP measurement□Update contact date□Update and add any new action plans
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Getting Started
The following scenario is designed to help you learn how to use the Patient Tracking Spreadsheet to facilitate management of high-quality evidence-based medical care in a behavioral health setting.
Checklists at the end of each section indicate Patient Tracking Spreadsheet skills learned.
To get started, please open the Patient Tracking Spreadsheet, and make sure you click “Enable Editing” and “Enable Content” in the yellow bar at the top of the page.
This scenario is meant to be used in conjunction with the Patient Tracking Spreadsheet Template Quick Start Guide, which contains further instructions for each column on the spreadsheet.
We recommend that you read each scenario first, and then enter applicable information into the spreadsheet. After you have entered the information, use the checklists at the end of each section to ensure you have included the appropriate pieces of information.
As a team, discuss what steps you would take with the client in each scenario. Remember to think about actionable steps and follow-up with the client and not just entering the data!
Justin, Case #678910
Initial Contact 4/15/2016: Justin is a 16 year old high school student who lives with his mom and dad and his little sister, Delphina. He enjoys skateboarding and drawing. A couple of times he has been in trouble for graffiti, but nothing serious. He enjoys art class at school, but otherwise just passes.
He was hospitalized last year after a suicide attempt by cutting his wrist, and at that time was diagnosed with bipolar depression. It took months for his depression to respond, and he eventually stabilized on medications including lithium 600 mg twice daily and quetiapine (Seroquel) 600 mg at bedtime. He and his family also see a therapist at the mental health center, who he likes, though he is often reluctant to take time to go to the appointments.
He has been able to return to the 10th grade, though not doing quite as well as he was before, and some of his friends were freaked out by his suicide attempt, and don’t really hang out with him anymore.
He has been adherent with his meds for the most part, except when he and his parents both forget, which happens especially on the weekend, when he sleeps in.
His psychiatrist, Dr. Woods, has been seeing him regularly, every 2 or 3 weeks and at today’s appointment his PHQ-9 was 8. He is 5’6” and his weight 160 Ibs.
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Practice the Following Registry Skills: □ Enter all possible new patient information fields□ Enter all known contacts and dates□ Enter all known measurements□ Enter the action plan you would take as the care team for Justin
Justin Follow-up Contact 6/1/2016 Dr. Woods saw Justin today. His PHQ-9 was now 10. And his weight had increased by 30lbs in six months to 180 lbs [BMI of 29.1 – in the overweight range, and not far from the “obese” threshold of 30.]
Justin feels hungry all the time, and sometimes gets up in the middle of the night to eat leftovers or ice cream. He is somewhat embarrassed about how heavy he has become, his friends tease him about it, and he is sure that this makes him unattractive to girls. Skateboarding is not as easy as it used to be, and he needs more breaks.
Dr. Woods has talked with Justin about “eating healthier”, and his mom has tried to feed him more fruits and vegetables, but he has felt unable to control his appetite.
As part of routine monitoring of his medications, Dr. Woods checked laboratory tests, including fasting serum glucose, which came back 82, in the normal range, and a lipid profile, which did not: total cholesterol 205, LDL 160, HDL 39.
Practice the Following Registry Skills: □ Enter all known contacts and dates□ Enter all known measurements□ Enter the action plan you would take as the care team for Justin
Justin Follow-up Contact 6/15/2016 On his return appointment with Dr. Woods, she discussed reviewed laboratory and physical findings and her concerns about his weight and his lipid profile, and educated Justin and his family about cardiovascular risk.
They made the following plan:
1. Pediatric appointment for Justin with Dr. Smith2. Dr. Woods to consult with pediatrician3. Consider change in psychiatric meds4. Exercise plan5. Diet plan
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Practice the Following Registry Skills: □ Enter all possible new patient information fields□ Enter all known contacts and dates□ Enter the action plans you would take as the care team for Justin
Justin Care Coordination Call 6/22/2016 The behavioral health care manager gives Justin a call to find out if he made an appointment with his PCP, Dr. Smith. He has an appointment on 7/20/2016. In addition the behavioral health care manager shared information about a community center in his area that has hour during the winter for a free open swim. They made a plan to start trying to exercise more with swimming.
Practice the Following Registry Skills: □ Enter all known contacts and dates□ Enter the action plans you would take as the care team for Justin
Case Load Review 9/2016 You are reviewing the case load and realize that the last communication that you had with Justin was in June. You follow-up with him to see if he made it to his PCP appointment and started swimming.
Registry Skills: □Review the caseload overview page for last contact information and BP measurement□Update contact date□Update and add any new action plans
The project described was supported by Funding Opportunity Number CMS-1G1-14-001 from the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.
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Introduction to Quality Improvement Methods Integrating Primary Care into Behavioral HealthWebinar 5
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Webinar objectives: • Discuss experiences completing registry case
activities.• Describe quality improvement principles to be applied
in a BHA setting.• Describe the rapid cycle improvement strategy and
the steps of a PDSA.• Give an example of a PDSA in a BH setting.• Identify next steps for PDSA sharing and discussion.
Learning activity after webinar:• Develop a rapid-cycle PDSA related to the measure you
are working to improve.
Learning Objectives
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More than half of the care delivered in U.S. is not consistent with evidence-based guidelines
– McGlynn, et al. N Engl J Med, 348 (2003):2635-45.
QI Methodology developed in other industries and applies to medicine
– Most of chronic disease management is protocol-driven; process standardization assures:
• Consistent quality• Lowest possible cost
– Chronic illness represents majority of diseaseburden
Why Use Quality Improvement Methodology in Medicine at All?
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• Three questions– What are we trying to accomplish?– How will we know a change is an
improvement?– What changes are likely to result in
improvement?• Rapid Process Improvement Cycles:
Plan/Do/Study/Act• Spread
The IHI Model for Improvement
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• Usually we jump to solutions
• Solutions entail change, which threatens thestatus quo
• It is very easy to think of reasons to resistchange, particularly when the goal isn’t clear
• Without a clear goal and measurable outcomesimprovement efforts bog down in resistance
Simple – Effective – Very Difficult
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• Problem statement: Mortality of mental healthpatients in the Medicaid population is 1.5 – 4times higher than matched controls
• This excess mortality is driven by:– Cardiovascular disease– Cancer– Chronic respiratory disease– Diabetes
Example 1 Applying this to Behavioral Health
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• Mental illness interferes with treatment of chronicillness
• Chronic illnesses frequently makes mentaldisorders worse
• Improving outcomes requires collaboration• Standardized processes required on both sides
– Medicine: recognize and address behavioralhealth issues effectively
– Behavioral Health: recognize and address chronicillness effectively
– Coordinated evidence-based care plans
Example 1Chronic Diseases Straddle both Disciplines
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Question 1: What are we trying to accomplish?
• Define a the target population – that meanshaving a list of every patient in the population
• Define a “standard of care” supported bymedical evidence
• Translate that standard of care into specific“care gaps” to be closed
Example 1Applying the Model for Improvement
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Example 1Caseload: Role of Registry
Registry
Advantages:• One person controls data entry
and reporting• Without an EHR analytics it’s
the only option• May be best fit for “case load”
concept in behavioral health
Disadvantages:• Separate data entry• People not in registry are
overlooked• Multiple registries are
cumbersome
Caseload data managed in the registry
New Patients
Patients finishing therapy
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Example 1Consider Blood Pressure Control
• Easy to measure – must be done right• Cardiovascular disease: greatest threat
to mental health patients• Hypertension: most powerful risk factor
for cardiovascular disease• Controllable with medication• Shared management solutions create
structure for collaboration– Between medicine & behavioral
health– With community resources
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• Define the target population: Adults > age 18receiving mental health care at our facility
• Define a standard of care:– Every adult patient of the clinic will have blood
pressure measured at each visit– The blood pressure for that visit will be
documented in the registry– If BP > 140/90, a standardized process will be
followed to hand the patient off to the medicalservice for management
Example 1What Are We Trying to Accomplish?
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Example 1 The Standard Defines the Care Gaps
People in target population: Active
patients we are managing
People whose BP was measured at
last visit
People with elevated blood pressure
People handed off to PCP for management
Process Care Gap 1
Process Care Gap 2
Clinical Care Gap
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A change that closes a care gap is an improvement• The percent of patients with a blood pressure
recorded at last visit• Percent of patients with BP > 140/90 for whom a
handoff to Medicine was initiated• Percent of patients handed off to Medicine for
whom the handoff was completed• Percent of patients with elevated BP
Example 1 How Will We Know a Change is an Improvement?
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Example 1Run Charts Make Gap Closure Visible
0
10
20
30
40
50
60
70
80
90
100
1st Qtr 2nd Qtr 3rd Qtr 4th Qtr 5th Qtr 6th Qtr
Clinic
Goal
Percent of patient with standard of care met
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Co-managing blood pressure means adding a few tasks to the workflow
• Gather information: Measure blood pressure onevery patient
• Decide: Make a decision as to whether it is normalelevated
• Act: Every patient with elevated blood pressure willleave with a plan for treatment in primary care
Example 1 What Changes are Likely to Result in an Improvement?
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Example 1Workflow: Patient Sees Therapist
Work to be inserted into this workflow1. Gather the information to make a decision2. Make a decision based on the information3. Act on decision
Things to decide:1. What are the tasks we want to do?2. Who will do each task?3. Where in the workflow will it be done?4. What will that person need to do the task?
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Example 1Future State Workflow
Care Gap 1 - Gather Information: Clinical Assistant takes and documents Blood Pressure; informs Clinician if elevated
Decide: Use protocol to initiate handoff for BP management and
informs Clinical Assistant
Care Gap 2 - Act: Clinical Assistant arranges
appointment with primary care according to protocol
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Task Who When
Purchase BP Machine
Designate individual to take BP
Train clinical assistant in proper BP measurement
Set up data entry field in registry for BP
Establish referral agreements for Pts without PCP
Train front desk to identify PCP at check-in
Set up order for referral to PCP
Example 1Tasks to Complete before Testing
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• Plan out every step of future state• Pick a team eager to make it work• Test it in a single practice, with a
single patient, a single day• What worked? What didn’t?• Modify it to make it work better• Test it again, expand to more
patients, more teams
Example 1Rapid Process Improvement Cycles
Plan
DoStudy
Act
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Example 1Repeated Use of the PDSA Cycle
The future state you planned
The future state as it
evolved using rapid process improvement
A PS D
A PS D
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Example 1Run Chart for Care Gap 1: Measuring Blood Pressure
0
10
20
30
40
50
60
70
80
90
100
1st Qtr 2nd Qtr 3rd Qtr 4th Qtr 5th Qtr 6th Qtr
Clinic
GoalStart taking BP at check in for Therapist appts
Spread to all patients
Large influx of new Medicaid
enrollees
Additional staffing to accommodate expanded Pt load
Front desk configuration change to make workspace
more efficient
Percent of Adults patients with BP reading at last visit
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• Information is gathered to make decisions andcarry out effective actions
• Take the BP correctly to avoid false positiveelevation
• If elevated repeat after resting quietly for 5minutes and use second reading
• If still elevated, it requires action
Example 1Using Clinical Information to Make Clinical Decisions
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• Set up a referral agreement with at least oneprimary care clinic
• Develop a protocol for acting on elevated BP– RN in BH clinic can take handoff, schedule follow
up, and provide educational support– Find out who patient’s PCP is and help patient
schedule an appointment– If patient has no PCP refer to clinic using
prearranged referral protocol– Referral tracking to assure patient keeps
appointment
Example 1Protocols Facilitate Action
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• What are we trying to accomplish?– Every patient whose BP is > 140/90 will receive a
medical evaluation according to standardprotocol
• Contact PCP office if patient has one• Refer to partner PCP practice if no PCP
• How will we know a change is an improvement?– Document blood pressure in the registry– Document handoff to PCP in registry– Verify handoff completed
Example 1PDSA Cycle for Care Gap 2
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• Use Lean thinking to identify waste– Verify name of PCP at check in
– If BP is elevated on second reading, have theperson taking BP set up handoff to PCP
– Make appointment with PCP before patientleaves BH office to improve keeping appointment
• Ask the people doing the work, what would maketheir jobs easier
Example 1Tactics for Identifying Changes That Should Result in Improvement
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• Obesity & depression prevalence in youth:– Depression: 2% in children; 4 – 8% in adolescents– Overweight increase from 14% to 17% since 1990s
• Emerging pattern of links between the two– Correlation is strongest in females– Similar presentation:
• Sleep disorder• Sedentary behavior• Increased appetite• Negative self-image
• Side effects of antidepressants– For each antidepressant prescribed 15% experience
increased appetite– 50% of children receiving anti-psychotic for first time have
a weight gain of 7% in the first 12 week.
Example 2What is the Problem?
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• Depression and childhood obesity appear linked• Improving outcomes requires collaboration• Standardized processes required on both sides
– Medicine: recognize and address depressioneffectively
– Behavioral Health: recognize and addresschildhood obesity effectively
– Coordinated care plans
Example 2Childhood Obesity Straddles both Disciplines
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Question 1: What are we trying to accomplish? • Define a the target population – that means
having a list of every patient in the population
• Define a “standard of care” supported bymedical evidence
• Translate that standard of care into specific“care gaps” to be closed
Example 2Applying the Model for Improvement
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Example 2Caseload: Role of Registry
Registry
Advantages:• One person controls data entry
and reporting• Without an EHR analytics it’s
the only option• May be best fit for “case load”
concept in behavioral health
Disadvantages:• Separate data entry• People not in registry are
overlooked• Multiple registries are
cumbersome
Caseload data managed in the registry
New Patients
Patients finishing therapy
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Example 2Consider Body Mass Index (BMI)
• Weigh & Height are easy tomeasure
• Shared management solutionscreate structure for collaboration– Between medicine & behavioral
health– With community resources
• Nutrition counseling• Opportunities for exercise• School-based programs
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• Define the target population: Youth receivingdepression care at this facility
• Define a standard of care:– Every child or adolescent will have height
and weight measured at each visit– The calculated BMI for that visit will be
documented in the registry– If BMI is > 30, or between 25 & 30 and
increasing, a standard process will befollowed to hand the patient off to themedical service for evaluation & management
Example 2What are We Trying to Accomplish?
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Example 2The Standard Defines the Care Gaps
Target population: Young people we
are managing
Young people whose BMI was measured at last visit
Young people with elevated BMI
Young people handed off to PCP for management
Process Care Gap 1
Process Care Gap 2
Clinical Care Gap
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A change that closes a care gap is an improvement• The percent of patients with a BMI was
documented at last visit• Percent of patients with BMI > 30 for whom a
handoff to Medicine was initiated• Percent of patients handed off to Medicine for
whom the handoff was completed• Percent of patients with elevated BMI
Example 2How Will We Know a Change is an Improvement?
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Example 2Run Charts Make Gap Closure Visible
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30
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1st Qtr 2nd Qtr 3rd Qtr 4th Qtr 5th Qtr 6th Qtr
Clinic
Goal
Percent of patient with standard of care met
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Co-managing obesity means adding a few tasks to the workflow• Gather information: Measure height and weight
on every patient • Decide: Make a decision as to whether BMI
meet threshold for action• Act: Every patient with elevated or increasing
will leave with a plan for involving primary care
Example 2What Changes are Likely to Result in an Improvement?
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Example 2Workflow: Patient Sees Therapist
Work to be inserted into this workflow1. Gather the information to make a decision2. Make a decision based on the information3. Act on decision
Things to decide:1. What are the tasks we want to do?2. Who will do each task?3. Where in the workflow will it be done?4. What will that person need to do the task?
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Example 2Future State Workflow
Care Gap 1 - Gather Information: Clinical Assistant gets height and weight and documents it; informs
Clinician if BMI elevated
Decide: Use protocol to initiate handoff for weight management and informs Clinical Assistant
Care Gap 2 - Act: Clinical Assistant arranges
appointment with primary care according to protocol
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Task Who When
Purchase scale and height measurement device
Designate individual to measure height & weight
Assure EHR calculates BMI from height & weight
Train clinical assistant in technique & scripting
Set up data entry field in registry for height & weight
Establish referral agreements for Pts without PCP
Train front desk to identify PCP at check-in
Set up order for referral to PCP
Example 2Tasks to Complete before Testing
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• Plan out every step of future state• Pick a team eager to make it work• Test it in a single practice, with a
single patient, a single day• What worked? What didn’t?• Modify it to make it work better• Test it again, expand to more
patients, more teams
Example 2Rapid Process Improvement Cycles
Plan
DoStudy
Act
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Example 2Repeated Use of the PDSA Cycle
The future state you planned
The future state as it
evolved using rapid processimprovement
A PS D
A PS D
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Example 2Run Chart for Care Gap 1: Measuring Body Mass Index
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GoalStart taking ht & wt at check in for Therapist appts
Spread to all patients
Large influx of new Medicaid
enrollees
Additional staffing to accommodate expanded Pt load
Front desk configuration change to make workspace
more efficient
Percent of Adults patients with BMI reading at last visit
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• Young people are highly sensitive to bodyimage
• Essential to get expert guidance on scripting– How to approach checking weight– What to say if BMI is > 30 or increasing– How to respond if patient refuses or
becomes emotionally upset
Example 2Scripting and Messaging is Essential
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• Set up a referral agreement with at least oneprimary care clinic– Find out what resources primary care has for
managing obesity in children and adolescents• Develop a protocol for acting on elevated BMI
– RN in BH clinic can take handoff, schedule follow up,and provide educational support
– Find out who patient’s PCP is and help patientschedule an appointment
– If patient has no PCP refer to clinic using prearrangedreferral protocol
– Referral tracking to assure patient keepsappointment
Example 2Protocols Facilitate Action
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• What are we trying to accomplish?– Every patient whose BMI is > 30, or between
25 – 30 and increasing will receive a medicalevaluation according to standard protocol• Contact PCP office if patient has one• Refer to partner PCP practice if no PCP
• How will we know a change is an improvement?– Document BMI in the registry– Document handoff to PCP in registry– Verify handoff completed
Example 2PDSA Cycle for Care Gap 2
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• Use Lean thinking to identify waste– Verify name of PCP at check in– Make appointment with PCP before patient
leaves BH office to improve keepingappointment
• Ask the people doing the work, what wouldmake their jobs easier
Example 2Tactics for Identifying Changes That Should Result in Improvement
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Components of Successful Change Management
Knoster, T., Villa R., & Thousand, J. (2000) A framework for thinking about systems change.
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• Use the PDSA Worksheet to implement PDSAs
Next Steps – Learning Activities
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PDSA Worksheet Page 1 of 2
PDSA Worksheet
Complete Page 1 of the worksheet when planning your Plan-Do-Study-Act (PDSA) cycle. Multiple PDSAs can be designed in support of a single Aim.
AIM STATEMENT (Measurable goal, with a target date)
___________________________________________________________
___________________________________________________________ Today’s Date: _____________________
___________________________________________________________ PDSA Cycle #: ____________________
___________________________________________________________________________________________________
PLANWhat will you try? _________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
When? ___________________________________________________________________________________________
Who will be involved?
Team: ____________________________________________________________________________________________
Patients: _________________________________________________________________________________________
What do you predict will happen? __________________________________________________________________
___________________________________________________________________________________________________
How will you evaluate how it went? ________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Who will collect the evaluation data? _______________________________________________________________
What do you need to do to get ready? ______________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
PDSA Worksheet Page 2 of 2
Complete Page 2 of the worksheet during your test and its follow-up assessment.
Today’s Date: ________________________
DOWhat actually happened? __________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
STUDYWhat did you learn? ______________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
How did the results compare to your predictions? ___________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
ACTHow will you adapt, accept, or abandon? ___________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
www.QualisHealthMedicare.org/PDSA
Adapted by Qualis Health from materials developed by the Institute for Healthcare Improvement and prepared under a contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. ID/WA-C10-QH-916-09-12
Used with permission from Qualis Health.
Thank you
The project described was supported by Funding Opportunity Number CMS-1G1-14-001 from the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.
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