Session #C1b
October 28, 2011
11:15 AM
San Diego System Transformation:
Implementation Lessons Learned,
Approaching the Tipping Point
Lauren Chin, MPH, Health Planning & Program Specialist,
Health & Human Services Agency, County of San Diego
Nora Cole, MEd, MFT, Associate Director, Mental Health Services,
Family Health Centers of San Diego
Shelly Tregembo, M.A., Administrative Analyst
Health & Human Services Agency, County of San Diego
Collaborative Family Healthcare Association 13th Annual Conference
October 27-29, 2011 Philadelphia, Pennsylvania U.S.A.
Faculty Disclosure
We have not had any relevant financial
relationships during the past 12 months.
Need/Practice Gap & Supporting Resources
25 year mortality disparity for those with Serious Mental Illness
(SMI); increased mortality is primarily due to chronic physical
conditions ( heart disease, stroke, diabetes, etc) – Improved
physical health care is important for this population.
Public Specialty Behavioral Health is a scarce commodity;
improved access for those who need specialty services is
achieved when stable SMI are managed in a primary care
medical home rather than specialty care.
Objectives
• Describe the integration of behavioral and primary health
care on site at three rural clinics.
• Describe a process for linking SMI with chronic health
conditions to primary care more successfully by accelerating
the eligibility process.
• Explore issues related to the transition of “stable” SMI to
primary care medical home for ongoing medication
monitoring and physical health care.
• Describe a system for pairing of mental health and primary
care clinics by region and neighborhood for coordinated
treatment and bidirectional referral
Expected Outcome
Identify resources and tools to develop or strengthen
relationships between behavioral health and primary care
providers; to increase capacity for mutual engagement in
shared population management to meet the physical and
behavioral health care needs of the SMI population.
Live Well, San Diego!
San Diego County
• Population: 3.2M; 4,300
sq. miles
• Urban, suburban, and
rural communities
• Ethnically diverse; 68
languages
• No county-run primary
care services
Complex Web of Safety Net Services
Physical Health
Behavioral Health
• 17 separate primary
care organizations
(FQHCs / non-profit
clinics)
• Approximately 100
individual primary care
sites
• Children/Youth: FQHC’s
and other health
systems (numerous
providers)
• County funded Mental
Health: 61,000 clients /
year
• ADS serves 12,000
clients / year
• Most services
contracted to
organizational providers
and/or FFS (Dozens of
clinics & programs)
Wagner Chronic Care Model
Community
Health System
Resources and Policies
Health Care Organization
SelfManagement
Support
Informed,
Activated
Patient
Delivery
System
Design
Productive
Interactions
Clinical
Decision
Support Information
Systems
Prepared,
Proactive
Practice Team
Improved Outcomes
San Diego Paired Provider Model ©
• Different governance & payment
• Generalists and Specialists Paired/partnering
provider organizations
• Continuum of care - Virtual PCMH’s
• Shared management of a SINGLE population,
“owned” jointly
– Bi-directional Flow (Clients and Info)
– Continuous access for all BH needs
Copyright © 2011 San Diego Health and Human
Services Agency
Integrated Care System
Bi-directional, seamless flow of clients and information
Behavioral
Health
Consultant
RN Care
Coordinator
BH
MD Only
FQHC
BH Program
Severity / Acuity
Recovery / Stability
Community / Peer Supports
PC
San Diego Paired Provider Model ©
What’s in it for Behavioral Health?
– Less acute clients to FQHCs
– Improve access for the most SMI
– Now have partners to attend to the
physical health needs of our shared
population
Copyright © 2011 San Diego Health and Human
Services Agency
San Diego Paired Provider Model ©
What’s in it for Primary Care?
• “The Triple Deliverables”
– Access for clients needing specialty MH
– Consultation
» Not just for SMIs
– Education of providers AND support
staff
Copyright © 2011 San Diego Health and Human
Services Agency
ICARE
Integrated Care Resources
Nora Cole, MEd, MFT
Family Health Centers of San Diego
ICARE
Integrated Care Resources
• Collaborative Pilot Project
– Family Health Centers of San Diego
(FHCSD)
– Community Research Foundation (CRF)
• Funded by County of San Diego
Staffing
•
•
•
•
•
•
•
Nurse Care Coordinator
Project Manager
Peer Specialists (3)
Eligibility Specialist
Behavioral Health Consultants (3)
Alcohol and Other Drug Counselor
Data Entry/Project Support
Sites
• CRF:
– Areta Crowell Center
• FHCSD:
– North Park Family Health Center
– City Heights Family Health Center
– Logan Heights Family Health Center
How it Works
CRF Discharge Planner (DP)
meets with client ready to
transfer care to FHCSD
If uninsured, potential transfer
is linked to CRF Eligibility
Specialist (ES)
DP notifies FHCSD site
Behavioral Health
Consultant (BHC) of
potential transfer; BHC
makes initial assessment
appointment
BHC schedules transfer an
appointment with the Alcohol
and Other Drug Counselor
(AOD) for an assessment,
unless AOD met with transfer
at Areta Crowell
BHC makes First
Appointment
with Physician Champion
(PC) or alternate
BHC introduces transfer to
Peer Support Specialist (PSS)
for support, resource
information, etc.
PC refers to specialty care
as needed
NOTE: Nurse Care Coordinator (NCC) out-stationed at
CRF for health screening of CRF participants and facilitate
link to FHCSD primary care if emergent health care issue
is identified – accessible to Areta Crowell program
participants regardless of transfer readiness.
Keys to Success
• Shared refinement of referral criteria
• Mutually developed referral process
• Well-rounded referral information packet at
transition
• Availability of same day consultation by
transferring party
• Expedited re-entry to CRF if needed
• Regular communication
How it is working so far
• Change is difficult for some; others are
confident their overall health will improve
• Physicians like having a team to work with,
especially the added AOD resources
• Therapists understand and value the model;
occasionally feel like salespeople with those
struggling with the transition
• Peers enjoy helping clear up
misunderstandings about systems
Workforce Issues
•
•
•
•
•
Education
Training
Orientation to team concept
Personal beliefs about mental illness
Turf
System-Wide Integration
Efforts in San Diego County
Shelly Tregembo, MA
HHSA Behavioral Health Services
System-wide Integration Efforts
Several pilots launched:
– Mental Health and Primary Care
Integration Services
– East County Integrated Health
Access pilot (ECIHA)
– MHSA PEI Rural Integrated
Behavioral Health & Primary Care
Services (SmartCare)
– MHSA Innovations- ICARE
System-wide Integration Efforts
• Mental Health and Primary Care
– 7 clinic organizations
– MHSA-funded
– SPS, Senior Promotoras, IMPACT
• SmartCare
– 3 rural clinics
– MHSA PEI
– behavioral health screening, evaluation,
education, short term counseling and
wellness activities
Recent Developments
• Integration Summit
• Integration Institute (I2)
• Psychiatric Consultation to Primary Care
(PC2)
• Low Income Health Program (LIHP)
Emerging Best Practices
• Find your champions of integration
• Employ the “right” people
• Develop MOUs and SOPs
• Deliver support to providers
The Road Ahead
• Patient-Centered Medical Homes
• 2014 and Healthcare Reform
• Outcomes-driven funding
• Accountable Care Organizations
How San Diego is Preparing
• Gaining system-wide buy-in for shared
population management
• Providing Access, Consultation and
Education
• Convening the first Integration Institute
Contact Information
• Lauren Chin, MPH
619-563-2702
lauren.chin@sdcounty.ca.gov
• Nora Cole, MEd, MFT
619-515-2318
norac@fhcsd.org
• Shelly Tregembo, MA
619-584-5049
shelly.tregembo@sdcounty.ca.gov
Live Well, San Diego!
Questions
&
Discussion
Session Evaluation
Please complete and return the
evaluation form to the classroom monitor
before leaving this session.
Thank you!