ENHANCED CARE COORDINATIONTO IMPROVE PATIENT OUTCOMES

Texas Council of Community Centers Annual Conference

Amber Gelino BSW Program Manager Chalee Rivers RN Director of Outpatient Medical Services Joshua Wheeler CCBHC Lead Coordinator

June 20, 2019

OBJECTIVES Describe the role of the Care Coordination team and how risk stratification is

used to determine population served Identify challenges and lessons learned with implementation of Certified

Community Behavioral Health Clinic Care Coordination

AGENCY OVERVIEW Mental Health for children, adolescents

and adults Substance Use Disorders 24-Hour Crisis Line, Outreach Homeless Veteran Intellectual and Development Disabilities

(IDD) Early Childhood Services (ECS) Integrated Care

AGENCY OVERVIEW Nearly 2,000 employees Serve more than 55,000 people every year About 400 services across Tarrant and

surrounding counties

CERTIFIED COMMUNITY BEHAVIORAL HEALTH CLINIC One of the original 8 centers for CCBHC in Texas Recipient of CCBHC Expansion grant in 2018 Results

Improved and expanded access to care Integrated mental health and substance use Enhanced care coordination Increased collaboration with community partners Patient and family centered care Trauma informed care

INTRODUCTION TO CARECOORDINATION

WHAT IS CARE COORDINATION?Care coordination is the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient's care to facilitate the appropriate delivery of health care services. (Agency for Healthcare Research and Quality)

CARE COORDINATION Focuses on triple aim

Improve patient experience Improve health Reduce cost

Must be patient-centered with inclusion of family and patients in process and outcome measures

Inter-professional teams must be established to promote care coordination for each population and each health care setting

CARE COORDINATION MODEL

ENHANCED CARE COORDINATION TEAM

RN Care Coordinator

Wellness Navigator PeersWellness

NurseDietician

CHALLENGES AND BARRIERS

STAFFING CHALLENGES Difficulty with staffing shortages Training Burn out Turn over

STAFF ADOPTION Change is hard Fear Identify change makers Get people involved at all levels Communicate, collaborate and

commit

DATA SHARING Issue with Electronic Health Record

“talking” with the county hospital system’s EHR Continuity of Care Documents (CCDs) Querying data

Connecting to other community providers Getting the “right” people in the room

CLINICAL IMPLEMENTATION

POPULATION HEALTH & CARE COORDINATION Wagner’s Chronic Care Model

Care coordination allows our health system working with the community to improve health outcomes

Improved Care Coordination Identify high risk individuals with one or more high risk chronic conditions Aggregate patient data - stratify into variables Barriers to care Implement interventions

WAGNER’S CHRONIC CARE MODEL

CARE COORDINATION ASSESSMENT TOOL Used to identify risk for behavioral and medical health Focuses on newly diagnosed, uncontrolled behavioral health, medical

conditions and social determinates of health Individuals who are identified as low to moderate risk will receive care

coordination from the Wellness team Individuals who are identified as high risk will receive care coordination from

the enhanced care coordination team

RISK STRATIFICATION DATA Psychiatric Diagnosis Medical Diagnosis Social Determinants

Housing Social Support Transportation

Hospitalization Risk Health Literacy

RISK STRATIFICATION AND CARE MANAGEMENT

Intensive Care Management: Example:Schizophrenia, Bipolar, or MDD +1 or more chronic diseases +Hospitalization or missed clinicappointments

Health Education and Promotion

Health Coaching & Lifestyle Management: Example:Schizophrenia, Bipolar, or MDD +1 chronic disease + social determinants health risks

Using Predictive Modeling to Assign Individuals Within the Care Management Disc

LEVEL 33% - High risk with

multiple chronic illnesses

LEVEL 2

15% - Moderate risk patients with single chronic illness or risk

factorsLEVEL 1

80% - Low Risk

CARE COORDINATION TEAM REFERRALHypertension 140/90 or greaterObesity (BMI of 30 or greater)Underweight (BMI<18.5)Lipids – Abnormal rangePHQ 9 Score 9 or higherNo PCP visits within the last 24 monthsA1C greater than 7COPDHeart diseaseAsthmaChronic pain

Must have 2 or more of the following:☐ 1 or more Inpatient admissions within the past 6 months ☐ 3 or more ED within the past 6 months ☐ 6 or more prescriptions currently ☐ 3 or more outpatient providers over the past 6 months ☐ No PCP visit within the past year☐ Schizophrenia or Bipolar Disorder☐ Prescribed Antipsychotic☐ Disabled or unable to work☐ Post-Partum Depression☐ Substance Abuse/Dependence

CASE STUDY

MEET VICKI White, female, raised by mother, father not present in home Completed 9th grade, did not receive GED Never married, had 1 child, raised by her mother First hospitalization occurred at the age of 15; for the duration of 6 months Began receiving psychiatric care in 1980 from Dallas County MHMR; later

moved to Fort Worth in 2002 and started receiving care from MHMR Tarrant County

At the time of her death, Vicki was living independently; she died at the age of 54 from complications during surgery to amputate right leg

PSYCHIATRIC AND MEDICAL PROBLEMS Schizoaffective Disorder, depressive type Cannabis Dependence, uncomplicated Nicotine Dependence, unspecified, uncomplicated Type 2 Diabetes HIV positive Elevated Cholesterol Left leg amputation below the knee in 2015 related to uncontrolled diabetes

PRESENTING PROBLEMS FROM INITIAL EVALUATION Chief complaint: “My mind gets so weak, that I can’t function.” Findings:

Auditory Hallucinations: Complains of hearing the voice of a man that raped her when she was a teenager

Disorganized Thinking including several topic shifts during evaluation Frequent cycling of depressive and manic episodes that resulted in risky

sexual behaviors, excessive spending, and racing thoughts Nightmares and flashbacks of being stabbed in a fight and also from rape

that occurred in youth

SOCIAL DETERMINANTS OF HEALTH Legal Issues

Several misdemeanor and felony cases due to: possession, prostitution, and forgery Hospitalizations

8 Psychiatric Hospitalizations in Tarrant County from 2002-2017 Frequent flyer in ER and Urgent Care facilities

Money Management Issues PTSD from rape Lack of family and friend support Housing Issues

Cleanliness Problems with landlord

Resilient Optimistic Resourceful Received Railroad Benefits and later

Supplemental Security Income Benefits

Non-Compliance with Medications Non-Compliance with Medical and

Psychiatric Care Drug Usage Lack of Support System Lack of Insight Low Socioeconomic Status

STRENGTHS BARRIERS

HOW COULD CARE COORDINATION HELP? RN Care Coordinator: Researching data on patients to deploy correct

members of the team to meet their needs, assigning tasks, and evaluating outcomes

Wellness Navigator: Linking to resources, following through with referral process to ensure appointments are kept

Wellness Nurse: injections in field, pillboxes, housing assessment, and Medication training and support

HOW COULD CARE COORDINATION HELP? Dietician: Evaluate health and diet needs, assisting with diabetes

management, creating diet plans Rehabilitative Case Manager: Using psychosocial rehab to address budgeting

concerns and housing issues Peer: Support “when others don’t understand” and linking to clinic and

community groups

SUCCESS STORY - CRAIG 46 year old, white male, diagnosed with Major Depressive Disorder, recurrent

severe without psychotic features Divorced twice, 4 children Moved to Texas from Seattle in 2016 to escape problems related to drinking Started treatment with MHMR Tarrant County in August 2018 after a 6 month

stay at hospital

BEFORE CARE COORDINATION Isolation and loneliness Housing problems Multiple suicide attempts Non-Compliance with taking prescribed psychiatric medications Frequent flyer of psychiatric hospital Unmanaged health problems

AFTER CARE COORDINATION Worked through psychosocial rehab with RCM to find housing 0 suicide attempts in the last 3 months 0 visits to the psych ER in the last 3 months Keeping weekly appointments with Wellness Nurse to fill pillbox Care Coordinator assisted with linking him to PCP; now on blood pressure and

cholesterol medication Plans to refer to Dietitian due to high BMI Became involved in Community Garden Group

RESOURCES Risk Stratification Tool User Guide: National Council for Behavioral Health:

https://www.thenationalcouncil.org/wp-content/uploads/2017/01/Care-Transitions-Network-VBP-Tools-User-Guide_Version-1.0_FINAL.pdf

Care Coordination: Blue Print for Action for RNs: American Nurses Association Publications: https://www.nursingworld.org/ana/

Wagner’s Chronic Care Model: http://www.improvingchroniccare.org/index.php?p=the_chronic_caremodel&s=2

Mental Health Community Health Needs Assessment (CHNA): http://www.healthyntexas.org/resourcelibrary/index/view?id=129993951028073535

CONTACT INFORMATIONAmber GelinoProgram ManagerAmber.Gelino@mhmrtc.org

Chalee RiversDirector of Outpatient Medical ServicesChalee.Rivers@mhmrtc.org

Joshua WheelerCCBHC Lead CoordinatorJoshua.Wheeler@mhmrtc.org