Session #G2
October 5, 2012
Integrated Care:
Where Clinical Need Intersects
Sustainability
Collaborative Family Healthcare Association 14 th Annual Conference
October 4-6, 2012 Austin, Texas U.S.A.

Where Clinical Need Intersects
Sustainability
Behaviorally Enhanced Health Care Home
Kimberly A. Arlinghaus, M.D.
Medical Director, Behavioral Health
Lone Star Circle of Care
Department of Psychiatry and Behavioral Health
512-686-0207 ext. 10375 karlinghaus@lscctx.org
Greg Jensen, LCSW, ACSW
Vice President for Behavioral Health
Lone Star Circle of Care
Department of Psychiatry and Behavioral Health
512-686-0207 ext. 10135 gjensen@lscctx.org
© 2009 Lone Star Circle of Care

Brian … 17 y/o HM
• PTSD, Bipolar d/o, Polysub abuse, ADHD
• 4 SAs 12-16 y/o
• Multiple psych hosp, BBT,
PP therapists, primary care
Carousel Pediatrics
• Psych meds by Carousel
• HTN, reflux, “passing out” w/hx of head injury
© 2009 Lone Star Circle of Care 2

Psychiatrist-Therapist Collaboration
• BH intake by therapist
• Psychiatric evaluation—added hx psychosis, TBI, and changed
BD to MDD; changed medications
• Ongoing med management, psychotherapy, and encouragement to enroll in
LSCC primary care
© 2009 Lone Star Circle of Care 3

Psychiatrist-Therapist-PCP Collaboration
• LSCC PCP visit
• Facilitated neurology work-up for TBI and question of seizures
• Obtained additional medical records
• Assisted with checking drug screens and monitoring suicidality
© 2009 Lone Star Circle of Care 4

Network Collaboration
• Seton ER
• Consultation with ER physicians
• Hospitalization
• IOP, 12-step
• LSCC for therapy, medication management, primary care
© 2009 Lone Star Circle of Care 5

The Bottom Line…Shared Care is Best Care
Right thing to do for the patient
Adds value to the community
Sustainable and scalable
© 2009 Lone Star Circle of Care 6

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Establish the vision and mission concepts necessary to create organizational commitment to integrated care
• Define governance, operational, financial and clinical issues to implement a behaviorally enhanced community health center
• Discuss critical sustainability success factors and challenges
© 2009 Lone Star Circle of Care 7

Every Central Texan who needs access to psychiatry and psychotherapy will have access to a fully integrated, behaviorally enhanced, healthcare home
© 2009 Lone Star Circle of Care 8

• Provide behaviorally-enhanced healthcare services to patients who have LSCC as their medical home
• Provide access to BH services in collaboration with community partners who have aligned and complementary goals
© 2009 Lone Star Circle of Care 9

LSCC Clinics
LSCC services offered in each city:
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Austin
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Family Medicine
Behavioral Health
Belton
‒ Pediatrics
Cedar Park
‒ Pediatrics
Georgetown
‒ Family Medicine
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Senior Health
Pediatrics
Behavioral Health
Pharmacy
Dental
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Harker Heights
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Pediatrics
Behavioral Health (child & adolescent)
Hutto
‒ Pediatrics
Killeen
‒ Pediatrics
Round Rock
‒ Family Medicine
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OB/GYN
Senior Health
Pediatrics (also Adolescent)
Behavioral Health
Pharmacy
Taylor
‒ Family Medicine
Temple
‒ Family Medicine
Lone Star Circle of Care / Locations
© 2009 Lone Star Circle of Care 10

Locations of LSCC Dedicated BH Clinics
© 2009 Lone Star Circle of Care 11

“The Usual Way”
Medicine
Mental Health Stigma
Psychiatry
Outsourced
© 2009 Lone Star Circle of Care 12

“The Lone Star Circle of Care Way”
Behavioral Health Providers (Psychiatrists and
Counselors/Therapists) are members of LSCC medical team thereby leveraging ALL Integrated
Delivery System benefits
© 2009 Lone Star Circle of Care 13

Integrated Care: Why Do It?
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Up to 70% of patients presenting for primary care have some type of behavioral health (BH) problem which impacts diagnosis and treatment
Patients are more likely to receive BH treatment if they are treated via an integrated model
Treatment of BH problems enhances medical outcomes and quality of life
Integrated care optimizes efficiency of health care delivery
© 2009 Lone Star Circle of Care 14

Depression and Diabetes
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95% of diabetes management is conducted by the patient
If the patient is depressed…
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Poorer outcomes
Increased risk of complications
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< glucose monitoring
< adherence to diet, exercise, and medication regimens
© 2009 Lone Star Circle of Care 15

Potential Systemic Effects of the “Depressed” Brain
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Sticky platelets
Decreased heart rate variability (HRV)
Increased C-reactive protein
Increased cortisol
© 2009 Lone Star Circle of Care 16

Systemic Effects of Cortisol
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Redistribution of body fat
High sympathetic tone
Elevated noradrenaline
Increased HR
Reduced HRV
Decreased insulin sensitivity
Decreased bone absorption of calcium
© 2009 Lone Star Circle of Care 17

Depression Worsens Outcome of Heart Disease
• Depression worsens morbidity and mortality after myocardial infarction 1,2
• Depression increases morbidity and mortality in patients with CHF 3,4
1. Frasure-Smith N, et al. JAMA. 1993;270:1819-1825.
2. Penninx BW, et al. Arch Gen Psychiatry. 2001;58:221-227.
3. Jiang W, et al. Arch Intern Med. 2001;161:1849-1856.
4. Vaccarino V, et al. J Am Coll Cardiol. 2001;38:199-205.
© 2009 Lone Star Circle of Care 18

Behavioral Cardiology (Pickering et al. 2003)
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The causes of heart disease lie not so much in the heart itself, but in the brain, or more specifically, the mind.
The mind affects the heart via:
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Our lifestyles
Effects of psychosocial stresses and how we cope with them
© 2009 Lone Star Circle of Care 19

Integrated Care Outcomes Research
Better Outcomes/Improved Functioning: Independent
Three-year Process and Outcome Evaluation
(Dr. Toni Watt, Texas State University. Commissioned by St. David’s Community Health Foundation, 2008)
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Statistically significant decrease in depression symptoms (32%) that remained constant over two, three and six month period
Selfreport measures showed patient’s physical health, daily living activities performance, ability to socialize improved significantly
Treating BH illnesses does not cost the overall health system more money. While there was an initial increase in costs, from 6-21 months post treatment, the costs remained stable
© 2009 Lone Star Circle of Care 20

An Institute of Medicine report in 2005 concluded that the only way to achieve true quality (and equality) in the health care system is to integrate primary care with mental health care and substance abuse services .
(Institute of Medicine, “Improving the Quality of Health Care for Mental and Substance-Use
Conditions: Quality Chasm Series”, November 1, 2005.)
© 2009 Lone Star Circle of Care 21

Integrated Care: What Differentiates LSCC’s Model
 BH and medical providers employed by LSCC
 BH and medical providers on the same HER
 LSCC treats ALL psychiatric groups
 BH records fully open to the medical providers
 Medical providers have immediate access to psychiatrists
 BH specialists embedded into the medical clinics
 Single governance structure that develops the integrated services
 Active mental health screening in medical clinics
 Psychiatrists actively treating patients vs. consultant
© 2009 Lone Star Circle of Care 22

Governance: Behaviorally Enhanced Healthcare Integration Council
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Provide guidance to and oversee integration implementation
Define and monitor outcome measures
Set professional practice standards such as defining and utilizing screening tools, establishing interdisciplinary care conferences, etc.
Establish reimbursement guidelines
Provide recommendations to LSCC Senior Leadership pertaining to the ongoing practice issues, resources and/or enterprise-wide impact of integration
© 2009 Lone Star Circle of Care 23

Addressing PCP Challenges: Time and Access
• Embedding behavioral health specialists
 Provide “real time” consultation to medical staff
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Conduct crisis intervention for patients in the clinic
Facilitate and expedite access to psychiatric services
Provide brief therapy/counseling services to patients
Coordinate care with the patient’s PCP
Assist with efficient patient flow
• Real time PCP consultation with child and adult psychiatrists
• Telepsychiatry
© 2009 Lone Star Circle of Care 24

The LSCC Integrated BH Model: Screening
Medical patients for mental health concerns
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TeenScreen for 11-17 year olds
PHQ 2 for depression
CAGE for substance use
Vanderbilt for ADHD
AD8 for cognitive decline in older adults
Edinburgh 3 for post partum depression
 MCHAT for autism
Behavioral health patients for medical concerns
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Primary care service provider (medical home)
Hypertension
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Obesity
Diabetes
Co-occurring substance use disorders
Tobacco product use
Pain
© 2009 Lone Star Circle of Care 25

LSCC’s Integrated Care Model
Providing holistic care by diagnosing and treating physical
AND mental conditions … together
BH screening in medical clinics
Embedding BH providers using open access
Providing PCPs direct access to psychiatrists
Interdisciplinary collaboration
Electronic health record
© 2009 Lone Star Circle of Care 26

Easy Access to Clinical Information: EHR
© 2009 Lone Star Circle of Care 27

Increasing Access
Lone Star Circle of Care Behavioral Health Visits
FY2005 - FY2012 (Projected)
2006-2012
1 to 17 prescribers
0 to 31 therapists
37 219
51 417
23 737
519
2005
10 000
1 119
2006
3 937
2007
5 023
2008 2009 2010 2011 Projected
FY2012
© 2009 Lone Star Circle of Care 28

Behavioral Health Visits By Patient’s Residence
Lone Star Circle of Care (LSCC)
Number of Behavioral Health (BH) Care Visits by City of Residence
Fiscal Year (FY) 2011 and FY2012 (Annualized)
15,000
12,000
9,000
6,000
3,000
FY 2011
FY 2012 (Annualized)
0
Austin Round Rock Georgetown Leander Killeen Cedar Park Pflugerville
City of Residence
Hutto Taylor Belton

Behavioral Health as % of Total LSCC Visits
Lone Star Circle of Care Visits
Fiscal Year (FY) 2005 - FY 2012 (Projected)
Behavioral Health Visits
Fiscal Year
2005
2006
2007
2008
2009
2010
2011
Total Health Visits
24,895
35,348
74,224
96,131
127,121
202,568
298,264
Number
519
1,119
3,937
5,023
10,454
23,737
37,219
Percent
2.1%
3.2%
5.3%
5.2%
8.2%
11.7%
12.5%
Projected 2012 360,832 51,417 14.2%
Source: Lone Star Circle of Care encounters occurring in FY2005-FY2011 and projections for FY2012.

% of Behavioral Health Patients with LSCC Medical
Home
Lone Star Circle of Care (LSCC) Behavioral Health Patients Medical Home Utilization
Fiscal Year 2011 (December 2010 - November 2011)
Did Patient Have a Medical Health with LSCC in FY2011?
Yes No
Most Recent Behavioral
Health Visit Paid By:
Total, all Payors
Medicaid/CHIP
Uninsured
Private Insurance
Total
6,801
2,745
2,520
936
Number
4,337
1,795
2,001
244
Percent
63.8%
65.4%
79.4%
26.1%
Number
2,464
950
519
692
Percent
36.2%
34.6%
20.6%
73.9%
Medicare 600 297 49.5% 303 50.5%
Source: Lone Star Circle of Care encounters occurring in FY2011 (December 1, 2010 - November 30, 2011).

Integrated Behavioral Health Sustainability and Scalability
• Provider Mix
 Psychiatrists AND therapists with same employer as medical providers
• Payer Mix
 Leverage FQHC to increase access to mission patients
• Productivity
 Goals by provider type
© 2009 Lone Star Circle of Care 32

Behavioral Health – Utilization (January 2012-August 2012)
LSCC BH Utilization, Jan 2012 – Aug 2012
80,0%
78,0%
76,0%
74,0%
72,0%
71,9%
70,0%
74,9%
73,3%
70,8%
71,9%
72,7% 72,5%
78,4%
68,0%
66,0%
Utilization
No Show Rate
January February March April May June July August
24.9% 23.9% 24.9% 26.3% 26.9% 27.9% 26.8% 26.7%
© 2009 Lone Star Circle of Care 33

Challenges: No Shows and Utilization
• No Show Policy
• Confirmation Calls
• Reverse Confirmation Calls
• Therapist-Based Intakes
• Same Day Call In List
• Intakes at Same Time and Overbook
© 2009 Lone Star Circle of Care 34

Integrated Behavioral Health Outcomes & Scalable Results
• Quality Metrics
 Symptom reduction
 Functional improvement (future)
 Access
 Assess safety at each visit
• Operational Metrics
 Volume
 Productivity
• Satisfaction Metrics
 Patient satisfaction data
© 2009 Lone Star Circle of Care 35

BH Training Partnerships
• Seton/UT Southwestern Psychiatry Residents
• Texas A&M Medical Students
• UT School of Social Work
• UT School of Educational Psychology
• UT College of Nursing
© 2009 Lone Star Circle of Care 36

Psychiatry and Behavioral Health – Community Partners
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• Texas A&M Health Science Center
Seton Family of Hospitals
University of Texas Southwestern /Seton Residency Program
St. David’s Foundation
Scott and White
Bluebonnet Trials
– Williamson County MH/MR
STARRY
Texas Baptist Children's Home
Caring Family Networks
Arrow Child and Family Ministries
Lighthouse Family Network
Central Texas Children’s Home
Texas Star Recovery Center
Department of State Health Services
Texas A&M School of Rural Public Health
University of Texas School of Social Work
Williamson County Mobile Outreach and Wilco MH Task Force
Wilco and ATCIC Community Providers
© 2009 Lone Star Circle of Care 37

New Initiatives in Behavioral Health
© 2009 Lone Star Circle of Care 38

Grant funded 6 month pilot at Crockett HS
March-August 2012
Clinic operational and seeing students
© 2009 Lone Star Circle of Care 39

© 2009 Lone Star Circle of Care 40

.
© 2009 Lone Star Circle of Care 41

Grant improves BH access
‒ Psychiatry ½ day/wk.
‒ Refer to therapy as needed
Medical home provided through LSCC PCPs
© 2009 Lone Star Circle of Care 42

© 2009 Lone Star Circle of Care 43

 St. David’s Foundation funds Lifework’s Shared
Psychiatric Services
(SPS) for short term psychiatric care
 LSCC’s provides a medical and BH home for children and their parents transitioning from SPS
© 2009 Lone Star Circle of Care 44

Family Drug Treatment Court/Parents in Recovery (FDTC/PIR)
Families identified by judicial and Child Protective
Services (CPS) due to mother’s substance abuse
Reduce children in out-ofhome placements and increase children reunited with families
© 2009 Lone Star Circle of Care 45

Family Drug Treatment Court/Parents in Recovery (FDTC/PIR)
Partnerships with Austin
Recovery and FDTC/PIR
Transition mothers and her infant/children into our medical and BH home
© 2009 Lone Star Circle of Care 46

Awards and Recognition
• Joint Commission Accreditation
 A nationallyrecognized “gold seal of approval” for health care providers
 Signifies that the safety and clinical qualify of care provided is exceptional
• Patient-Centered Medical Home (Level 3) recognition
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A recognition awarded by the National Committee on Quality Assurance
Less than 0.5% of all primary care providers in the nation have this prestigious designation
© 2009 Lone Star Circle of Care 47

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