Managing Care While
Staying in the Moment
October 8, 2015
Learning Objectives
1. List and describe the core components of the
IMPACT/Collaborative Care model of care
2. Identify ways to blend IMPACT and other evidencebased models such as behavioral health consultation
3. Describe the IT and clinical infrastructure needed to
provide population-based primary care behavioral
health
4. Identify the value of participating in a learning
collaborative
Definition of Integrated Care
• The care that results from a practice team of primary
care and behavioral health clinicians, working together
with patients and families, using a systematic and costeffective approach to provide patient-centered care for a
defined population
• This care may address mental health, substance abuse
conditions, health behaviors, (including their
contribution to chronic medical conditions), life stressors
and crisis, stress-related physical symptoms, ineffective
patterns of health care utilization
Peek, C.J. National Integration Academy Council (2013). Lexicon for behavioral Health and Primary
Care. Integration: Concepts and Definitions. Developed by Expert Consensus. In Agency for
Healthcare Research and Quality
The “Face” of Integrated Care
•
78 year old male whose family reports depression, agitation, and memory loss. Presents to
PCP who orders neurology referral and involves BHC. BHC does phq9 and Montreal
cognitive assessment and determines fairly major impairment and depression. SSRI
discussed, but patient isn't interested. Never goes to neuro. Later on, he shows up as a
transition of care from a psychiatric hospital and is discharged on 2 Alzheimer's meds,
Seroquel, and Prozac. Our PCP is very nervous about continuing those meds but consulted
with our psychiatrist who educated on the why, advised on what questions to ask the family
to determine the root of some of the issues they are seeing, and advised on some possible
dosage changes. The PCP was then able to prescribe and the BHCs worked with the family
to check in on the depression. The goal for this patient was to keep him out of
hospitalization. What the patient really wanted was to go back to Mexico, so the BHC also
worked on developing a plan to support this with the patient's daughters who were initially
unsupportive.
The “Face” of Integrated Care
•
Patient presents to PCP as depressed with main complaint lack of sleep, no
appetite, no interest in doing things, irritability, and recent negative
changes at work. He reported insomnia and trouble at home due to the
aforementioned reasons. Had failed SSRI trials previously. Got referred to
BHC and provider had already started on a tricyclic but he hated it. He had
a BHC consult to work on identifying priorities, skill building, general
support and a PHQ 9 initial score 15. With psych consult, decided to switch
to Remeron. After three weeks he came back and was a changed man. The
phq9 went down to 4. He decided to stay on the Remeron for two more
months but his depression was so improved and with his new skills he had
resolved so many of his source issues that he came off. We still touch base
when he comes in to see PCP but the adjustment disorder has completely
resolved and he knows we are there when he needs us.
Rarely Only Behavioral Disorder
Cancer
10-20%
Neurologic
Disorders
10-20%
Chronic
Physical Pain
25-50%
Mental Health/
Substance Use
Smoking,
Obesity,
Physical
Inactivity 4070%
Diabetes
10-30%
Heart
Disease
10-30%
What does work?
Core Principles of IMPACT/Collaborative Care
•
Patient-centered team care/Collaborative Care
– Collaboration not co-location
– Team members have to learn new skills
•
Population-based care
– Patients tracked in a registry; no one falls through the cracks
•
Measurement-based treatment to target
– Treatments are actively changed until the clinical goals are achieved
•
Evidence-based care
– Treatments used are evidence-based
•
Accountable care
– Providers are accountable and reimbursed for quality of care and clinical
outcomes, not just the volume of care provided
Collaborative Care Team Care Model
Two processes:
1. Systematic diagnosis and outcomes tracking
– PHQ-9 to facilitate diagnosis and track
depression outcomes
2. Stepped Care
– Change treatment according to evidence-based
algorithm if patient is not improving
– Relapse prevention once patient is improved
Primary Care Provider Role
• Oversees all aspects of patient’s care
• Diagnoses common mental disorders
– Brief screeners (e.g., PHQ-9, GAD-7)
• Starts & prescribes pharmacotherapy
• Introduces collaborative care team and care manager
• Collaborates with care manager and psychiatric
consultant to make treatment adjustments as needed
One Treatment Plan
• Team-based care: patient,
PCP, BHC, psychiatrist all
involved in developing
and carrying out the
treatment plan
• Regular communication
through team huddles,
shared appointments
• All members of the team
give consistent
recommendations
Two New “Team Members”
Behavioral Health
Clinician (BHC)
Consulting
Psychiatrist
• Patient education/selfmanagement support
• Close follow-up to make sure
pts don’t ‘fall through the
cracks’
• Support anti-depressant Rx by
PCP
• Brief counseling (behavioral
activation, PST-PC, CBT, IPT)
• Facilitate treatment
change/referral to mental
health
• Relapse prevention
• Caseload consultation for care
manager and PCP (populationbased)
• Diagnostic consultation on
difficult cases
• Consultation focused on
patients not improving as
expected
• Recommend additional
treatment/referral according
to evidence-based guidelines
BHC Role
• Supports and collaborates
closely with PCPs managing
patients in primary care
• Patient education/selfmanagement support
• Brief counseling (behavioral
activation, PST-PC, CBT, IPT)
• Support anti-depressant Rx by
PCP
• Supports medication
management by PCPs
• Reviews cases with psychiatric
consultant weekly
• Facilitate treatment
change/referral to mental
health
• Relapse prevention
Psychiatric Consultant Role
• Caseload-focused consultation supported by BHC
• Better access:
– PCPs get input on their patients’ behavioral health
within a day/week vs. months
– Focuses in-person visits on the most challenging
patients
• Regular communication:
– Psychiatrist has regular (weekly) meetings with the
BHC
– Reviews all of the patients who are not improving and
makes treatment recommendations
Measurement-Based Care (PHQ-9)
• Assists with identification and diagnosis
• Tracks 9 core symptoms over time
• Easy to use: can be self-administered and done over
the phone
• A good communication and teaching tool
• Available in many languages:
http://www.phqscreeners.com/
Population/Care Management
• Use a clinical registry to:
– Proactively follow up to prevent people from
‘falling through the cracks’
– Systematically track treatment response
– Facilitate treatment planning and adjustment
• Combat ‘clinical inertia’: patients staying on
ineffective treatments for too long
– Know when it is time to get consultation/get help
and when it is time to change treatment
Depression Registry
Outcome Aim:
Depression Improvement
Outcome Aim information:
Number of patients with a PHQ-9 >10
0
Number of patients with >50% improvement
0
Assessment month:
Reassessment month:
ID (non-PHI)
Instructions:
Please enter the
individual's identifier in
the blue column.
Please enter the dates
of the indivdual's first
and second PHQ-9
assessments in the
green columns.
Please enter the
indivdual's first and
second PHQ-9 scores in
the purple columns.
Please do not enter or
delete the numbers in
the Days Apart or %
Change columns - these
compute automatically.
As of:
Date of 1st
PHQ-9
1st PHQ-9
Score
Date of 2nd
PHQ-9
2nd PHQ-9
Score
Days Apart
Average Days apart:
Average % Change:
9/17/15
% Change
2nd
Assessment
Due
i2i Tracks
Population Management Software
Integrates data from internal and external systems, aggregating data
about your entire patient population.
i2i Tracks
Transforming Practice
Through Participation in a
Learning Collaborative
What is a learning collaborative?
Structured
approach for
change
Adopt best
practices in
multiple settings
Time-limited
learning process
Uses adult
learning
principles &
techniques
Shared learning
and
collaboration
Breakthrough LC Model
http://www.ihi.org
Components of Our LC
• Learning
Sessions
Training
Manuals
Apply Skills
Test Changes
• Action
Periods
• Collaborative
Meetings
Ongoing TA
& Support
Share
Progress
• Measure
Outcomes
Learning Collaborative Process
Create
Change
Package
Implement
Action
Periods
Develop
Charter
Hold
Learning
Sessions
Select Teams
Begin PreWork
Measure
Progress
The Charter
• Mission
– Primary focus of the collaborative
• Aims
– Written statements of expected accomplishments
• Expectations
– Commitments to meet during LC
• Community Care
• Provider agencies
• Other partners
Aims
• Process Aim 1:
– By March 31, 2016, 100% of adults, age 18 years and
older, are screened for depression using the PHQ-2
within the previous 12 months
• Process Aim 2:
– By March 31, 2016, 50% of individuals with a PHQ-9
score >10 are seen by the behavioral health clinician
• Outcome Aim 1:
– By March 31, 2016, 50% of individuals with a PHQ-9
score >10 have a 50% improvement in score after 3
months of treatment
Select the Teams
• Quality Improvement Teams (QIT)
– Executive leadership
– Clinical/quality improvement
– Leadership
– Lead behavioral health provider
– Health center patient
– Psychiatrist
• Intervention faculty
– Content experts
• Support and TA teams (Community Care staff)
Milestones
PDSA Cycles: Plan-Do-Study-Act
• PDSA cycles are how aims are achieved
• Small tests of change
• Conduct one or more each month
• Measure impact
• Submit workbook to producer
• Share progress in monthly collaborative calls
PDSA Cycle August
BEGIN DATE:
8/3/15
DATE COMPLETED:
Milestone/Fidelity: Improve overall behavioral health of BCHC patients
PLAN
What is your objective? Engage in a pro-active stance by earlier identifying patients with moderate
depression rather than moderately severe or severe depression.
What question(s) do you want to answer
on this PDSA cycle? By using PHQ 9 screening tools are we able to identify patients with moderate
depression earlier thereby have better outcome aims with 50% improvement?
Number of patient referrals to BHC may increase/decrease, decrease need for
What do you predict will happen? traditional outpatient mental health services, greater focus on relationship
between physical and mental health conditions which may improve patient
general wellbeing.
What is your specific plan? PHQ 9 will be given by PSRs to patients during registration process. MA will
collect and document PHQ 9 in EMR,if PHQ-9 is >10, patient will be informed
of BHC onsite. In addition, PCP will review PHQ 9 score and discuss with
patients the recommendation to see BHC onsite. Follow up with warm off hand
to BHC onsite.
DO
Did you carry out your plan?
□ Yes
Summarize what happened.
STUDY
What did you find out? Compare your
observation/data to your predictions
and summarize what you learned.
ACT
What is your next logical step?
Move on and develop a new PDSA cycle based on what you learned in this one.
□ No
Measure Progress on Aims
• Update monthly Excel workbooks
– Pre-formatted
– Automatically graphs progress
– Submitted monthly to producer
– Reviewed by facilitator
– Shared with collaborative
• Synthesized in quarterly reports
• Summative final report
Process Aim 1
By March 31, 2016, 100% of adults, age 18 years and older,
are screened for depression using the PHQ-2 within the
previous 12 months
Process Aim 2
By March 31, 2016, 100% of patients with a PHQ-9 score
>10 are seen by the behavioral health provider
Outcome Aim
By March 31, 2016, 50% of patients with a PHQ-9 score >10
have a 50% improvement in score within 3 months
Monthly Progress Assessment
Questions
Contact
Suzanne Daub, LCSW
Senior Director, Integrated Care Initiatives, Community Care
daubs@ccbh.com
Amy Lambert
Director, Behavioral Health, La Comunidad Hispana
alambert@lchps.org
Helen Wooten, LCSW
Behavioral Health Consultant, Berks Community Health Center
hwooten@berkschc.org