Integrated Health:
Creating Successful Outcomes Through
Technology Innovations
Mary Jo Whitfield, MSW
VP Behavioral Health Services
Cheri DeBree, MC
Integrated Health Director
Robin Trush, MA
Director of Special Projects
Presentation Objectives
 Gain insight into successful integrated health
programmatic elements: Clinical &
Operational
 Learn how the JFCS electronic health record
(NextGen) assists in clinical decision making
 Learn how to operationalize data and
outcomes to manage program elements
 Increase audience knowledge about
technology advancements and the use of
data exchanges
Why Integrate Physical and
Behavioral Health Care?
•
Behavioral and physical health care have
historically operated in silos.
•
Health care integration is designed to:
•
•
•
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Improve patient access to care in a setting where
patients are most comfortable.
Reduce health care disparities.
Contain costs by promoting a whole health
approach.
Improve patient outcomes through coordination of
care.
Key Drivers of Integrated Health
• Patient Protection and Affordable Care
Act
• State Health Insurance Exchanges
• Mental Health Parity
• Medicaid Expansion
National Driver: Affordable Care Act
• Health Insurance Exchanges
• Mental Health Parity
• Medicaid Expansion
Models of Integrated Care & Benefits
• Coordinated Care
• Co-Located Care
• Transformed/Full Integration
• Virtual Integration
Jewish Family and Children’s Services
…Who are we?
• Outpatient Behavioral Health Provider - Maricopa County
• In operation since 1935
• JFCS is Currently serving 5,025 adults and 4,838 children and has
about 90% Medicaid client population
• Our enrollment reflects the cultural diversity of our county
• Magellan Behavioral Health of Arizona
• Community Re-investment Grant
Integrated Health Program Data
• Adult Program began May 1, 2012
• Children’s Program began August 1, 2013
• 1750 adult clients served
• 134 Child clients served to date
• 750 active clients in the program typically
• 2,800 Health Risk Assessments have been collected
• 60% opt in rate as new clients to JFCS
Integrated Health Program Data
•Collaborative relationship with MIHS since
August, 2010, a Federally Qualified Health
Center look alike
• 4 clinics across Maricopa County
• 11 Health Navigators
Integrated Health
Client Demographics
Ethnicity of all Clients at JFCS
2% 1%
10%
29%
58%
Ango/White
Hispanic/Latino
African American
Native American
Other 1%
Overall Gender Breakdown
Female 46%
Male 54%
Children’s Population
Girls 32%
Boys 27%
Children Only
Age 0 -2
6%
Age
Demographics
Age 14 – 17
30%
Age 3 – 5
22%
Age 0-2
Age 3-5
Age 6-13
Age 14-17
Age 6 – 13
42%
Currently Serving 4,800 Children
All Clients Age Demographics
1%
23%
4%
13%
Age 0-2
Age 3-5
Age 6-13
9%
25%
Age 14-17
Age 18-30
7%
18%
Age 31-49
Age 50-64
Age 65 +
Mental Health Diagnosis Analysis For
Children
3%
ADHD/ADD
4%
Mood Disorder
10%
3%
2%
26%
Other
Neglect of Child
Bipolar Disorder
7%
Anxiety
13%
Depression
Adjustment Disorder
16%
16%
Autism
PTSD
Medical
Conditions
Analysis for
Children
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
80%
7%
4%
2%
2%
1%
4%
Behavioral
Health
Diagnosis
Analysis
for Adults
Chronic Disease Analysis for
Adults
Integrated Health Objectives
Objective 1: Assist behavioral health recipients in
establishing/maintaining an ongoing, lasting relationship with
a primary care provider.
Objective 2: Facilitate improvements in the physical health of
behavioral health recipients including EPSDT for children
Objective 3: Improve the mental health of behavioral health
recipients.
Objective 4: Enable behavioral health recipients to increase
control over their health.
Objective 5: Improve collaboration between behavioral health and
the client’s medical team through the use of a health
information infrastructure that includes an electronic medical
record and shared health information.
PCP
Relationship
• Investigate families current
relationship with Primary Care
Physician (PCP) and other
medical providers
• Is client is satisfied with
current PCP
• Maricopa Integrated Health
System
• Assist client in changing PCP
with AHCCCS
• PCP Notification – auto faxed
from EHR
• Release of information with
medical provider to share
information
• Assist client in scheduling first
appointment with MIHS
• Attend medical appointments
with family as an advocate
• Assist foster families in
retrieving medical history
Improving
Physical Health
• Explore families recent medical visits and history
• Satisfaction with current PCP
• Maricopa Integrated Health Systems
• EPSDT for children
• Nutrition Basics and for specific diagnoses
• Transportation to appointments if needed
• Compiling of medical records
• Medical decision making
• The importance of physical exercise
• Improved coordination and collaboration between medical and
behavioral health through HIE and other efforts
Improving
Mental Health
Educating families on the
importance of taking care of
their physical health also
improves their mental
health and vice versa.
• Working with the BH
teams
• The Bully Project
• Nutrition for specific
mental health diagnoses
• Relaxation
• Medication reconciliation
• Tobacco education
Client Quote on
Integrated
Care Services
“I have been a patient at JFCS for several years now and have
received exceptional care. My life has improved since I first
came here and I am grateful. However, since I was first
introduced to Integrated Health by my peer navigator, the care
I receive has become much more meaningful. Not just the
behavioral health care, the physical health care I receive has
improved as well. I say this because Adrienne has enlightened
me to the fact that physical and emotional well being are
inter-connected and cannot improve if either is neglected.“
- Anonymous satisfaction survey comment
Increased Control in
Overall Health
•
•
•
•
•
•
•
•
•
•
Teaching self management skills
Health education
Informed decision making skills
Health literacy skills equips the entire family to improve
ability to manage health
Empowerment and assertiveness skills
Nutrition, exercise, and self care Information
Resources
Social support development
Family and child only exercise programs
Flex funds for program related items, ie: karate
Social
Supports
One of the most
important
components of
human resiliency is
social support.
Research supports
the importance of
social supports in
health outcomes.
Relaxation and Stress Management Classes
Quote from a enrolled client:
“The relaxation class helps me to cope with my problems better and
helps me think in a more positive way. I really enjoy coming and being a
part of this two days a week. I feel like it is empowering me, making me
stronger as a person, more positive, and healthier in my lifestyle. This is
a wonderful program.”
- SF, Adult Integrated Health Client
Nearly 60-90% of visits to
healthcare professionals are
either caused or exacerbated by
stress for adults.
The Relaxation
Response
Research shows the Relaxation Response is an essential
resiliency self-management skill that is as predictable as
medication in immediately reversing the stress-induced
flight-or-fight response.
-Benson, H. The Relaxation Response, William Morton and Company, 1975
Let’s Do It!
EMPOWERING
CLIENTS
Helping clients gain the knowledge, skills, and attitudes for coping
with changes in lifestyle and circumstances
• Learning to help themselves and their family
members, manage their own care
• Greater confidence in themselves
• Increases clients and parents understanding of
the medical system
• Greater ability for the client to meet their own
needs and/or the needs of their children
• Gives clients knowledge that they can share
with others
Continuity of Care Document:
A patient summary containing data of the most
relevant administrative, demographic, and clinical
information facts about a patient's healthcare,
covering one or more healthcare encounters. It
provides a means for one healthcare practitioner,
system, or setting to view all of the pertinent data
about a patient and forward it to another
practitioner, system, or setting to support the
continuity of care.
Six Mandated CCD
Data Elements:
1. Header/Document Identifying Information
2. Patient Identifying Information.
3. Patient’s Insurance and Financial Information.
4. Health Status of the Patient
5. Care Documentation includes some detail on the
patient-clinician encounter history, such as the dates
and times of recent and pertinent visits and the
purposes of the visits and names of clinicians or
providers
6. Care Plan Recommendation includes planned or
scheduled tests, procedures or regimens of care.
Health Information
Exchange JFCS
and MIHS
Sharing client data between JFCS and MIHS on
two fronts utilizing the current CCD standard:
•JFCS can pull CCD from MIHS and bring in to
EHR
•JFCS can pull CCD from our EHR and fax
over to MIHS for inclusion in their client
record
Health
Risk
Assessment
Date completed:
Printed Name Person completing form:
Name:
Date of Birth:
Male ____
Parent/ guardian name providing info.:
Female ___
Age:
Contact phone number:
Vital Signs:
Are all immunizations up to date? Yes_____
Hei ght:
Does your child/youth have any allergies:
No_____
Wei ght:
BMI:
Does your child/youth have at least one friend he/she sees regularly? Yes ____
Bl ood Pressure (> 3 y.o.):
Has your child/youth ever been the victim of bullying? Yes
Pul se Rate:
On average how much daily physical activity does child/youth get per week?
Respi ratory Rate:
0 to 1 hours: _______
1 to 2 hours: _______
Has your child/youth ever been to the dentist?
Yes______
No ______
Has he/she seen a dentist in the last 6 months?
Yes______
No ______
Are you aware of any unresolved dental issues (cavities, misalignment)?
Date of last visit to primary care physician:
______
No____
No ______
3+ hours: _______
Yes______
No ______
PCP name and phone number:
Has a consent for records to include EPSDT form and laboratory tests been completed?
If yes, date faxed to PCP office:
Yes______
Have records been received from PCP?
Did your child/youth have a different PCP before the one named above?
Yes______
No ______
Yes______
No ______
No ______
If yes, previous PCP name and phone number:
Has your child/youth had a visit to a medical ER or hospital in the past 6 months?
Yes _______
No _______
Does your child/youth have any of the following chronic medical conditions:
Asthma
Yes______ No ______ Ski n Probl ems
Yes______ No ______ Heart di sease
Yes______ No ______
Di abetes
Yes______ No ______ Eati ng Probl ems
Yes______ No ______ Hi gh bl ood pressure
Yes______ No ______
Sei zures
Yes______ No ______ Sl eepi ng Probl ems
Yes______ No ______ Heari ng Probl ems
Yes______ No ______
Anemi a
Yes______ No ______ Obesi ty
Yes______ No ______ Speech Probl ems
Yes______ No ______
List all current medications that your child/youth takes:
Name of Medi cati on
Dose
Frequency
Has your child/youth ever had blood work done?
Yes ______
No ______
If yes, were any results abnormal?
Yes ______
No ______
Which ones were you told were abnormal?
Significant life events:
To be completed by BHMP
Chi l d Protecti ve Servi ces i nvol vement Yes______
No ______
HDL:
Legal system i nvol vement
Yes______
No ______
LDL:
Death of fami l y or fri end
Yes______
No ______
Total chol esterol :
Di ffi cul ti es i n school
Yes______
Willingness to Participate:
In the next si x months woul d you
parti ci pate i n a program that woul d
Yes______
hel p you i mprove your overal l
If avai l abl e, woul d you l i ke fol l owup servi ces and i nformati on to
Yes______
i mprove
Concerns you have about child's/youth's health:
No ______
Tri gl yceri des:
Fasti ng gl ucose:
No ______
No ______
Ye s
Le ve l
no
Reporting
 HRA Report
HRA Comparison Report
Integrated Health Update Report
Client Caseload Tracker Report
 Daily staff productivity reports
 Billed services and unit reports
 Appointments kept, no billing has occurred
Outcomes
PCP Relationship Outcomes and Baseline:
• We have assisted 66% of clients needing a better relationship with their PCP
• 75% of surveyed clients reported IH Program helped them develop better PCP
relationship
• 86% of surveyed clients reported better coordination of care amongst health providers
Improved Physical Health:
• We have delivered resources and information regarding health and wellness to 80% of
our clients in the IH program
• 39% of clients needing screening or routine testing received it
• 55% Of clients walking in with untreated chronic medical disease, received medical
appointment within 45 days of beginning the program
• 33% of clients that reported not managing their diabetes are now successfully managing
it and have reduced their A1C levels to below 9%
• 77% of surveyed clients report they feel an improvement in overall physical health
Outcomes
PCP Relationship Outcomes and Baseline:
• We have assisted 66% of clients needing a better relationship with their PCP
• 75% of surveyed clients reported IH Program helped them develop better PCP relationship
• 86% of surveyed clients reported better coordination of care amongst health providers
Improved Physical Health:
• We have delivered resources and information regarding health and wellness to 80% of our clients in
the IH program
• 39% of clients needing screening or routine testing received it
• 55% Of clients walking in with untreated chronic medical disease, received medical appointment
within 45 days of beginning the program
• 33% of clients that reported not managing their diabetes are now successfully managing it and have
reduced their A1C levels to below 9%
• 77% of surveyed clients report they feel an improvement in overall physical health
Technology
Landscape
 HITECH Act
Office of the National Coordinator (ONC)
EHR Interoperability: Data Set Selection
Electronic Health Records (EHR): Certification
 Meaningful Use – Incentives
 Privacy: HIPAA and 42 CFR Part 2
 Heath Information Exchange: State Grants $16 M
Hospital
Lab
Specialist
HIE
PCP
Pharmacy
HIE Benefits
 Connects multiple organizations with data
Coordinates care through information exchange
Shares information real time and efficiently
Improves quality and costs of services
 Avoiding duplication of tests
 Improved decision making based on data availability
 Improved experience for the individual: safety impact
HIE Data
Items
 Demographics
Diagnosis
Allergies
Prescribed Medications
 Lab Results
 **Documents: Progress Notes, Treatment and
Crisis Plans, Summaries
Community
Education
 State Adoption and Use Varies
 Behavioral Health: Nebraska and AZ
 Medical Provider Use – Who is Using an HIE?
Informed Consent
 Opt In – Must opt-out, in HIE by default
 Opt Out – Must opt – in, out of HIE by default
Education
Strategies
 Marketing Campaign
 Education of Health Care Professionals
Education of Heath Care Recipients
Medical v. Behavioral Health Differences
 Arizona Lessons Learned
 Input from Audience
Patient
Portal
Psych
Pharmacy
Hospital
BHINAZ
HIE
Crisis
Provider
OP BH Clinic
ER
Resources
 http://www.healthit.gov
 HIE Grants by State
 Programs and Advisory Committees
 Patient and Families Information