Integrated care at the providence center 2014
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Integrated Care at The Providence Center 2014. Presented by: Nelly Burdette, PsyD Director of Integrated Care The Providence Center. Background. Rhode Island’s largest community mental health organization with an annual budget of $42 million.

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Integrated care at the providence center 2014

Integrated Care at The Providence Center 2014

Presented by:

Nelly Burdette, PsyD

Director of Integrated Care

The Providence Center


Background

Background

Rhode Island’s largest community mental health organization with an annual budget of $42 million.

In 2013, we served 12,777 people with services provided statewide through 14 service locations in Providence, Burrillville, Cranston, Pawtucket, and Warwick, and 13 client residences in Providence.

5 main service divisions

  • Adult (SPMI and Health Home)

  • Child and Family

  • Wellness, Employment and Education

  • Residential Services

  • Crisis Care

TPC’s main administrative offices and adult outpatient services on North Main Street in Providence.


Tpc demographics

Gender

54% Male

46% Female

Age

0-3: 1%

4-8: 5%

9-12: 5%

13-18: 12%

19-34: 21%

35-50: 29%

51-64: 22%

65+: 5%

Race and Ethnicity

White: 43%

Latino: 21%

Other/Unknown: 18%

Black: 13%

Native American: 3%

Asian: 2%

Primary Reimbursement

Medicaid UBH: 19%

Medicaid NHP: 17%

Medicare: 14%

Medicaid: 16%

BCBS: 5%

Uninsured: 4%

Private: 2%

TPC Demographics


Tpc primary diagnoses

Most common across TPC (n=7501)

Depression:26%

Adjustment D/o: 11%

Schizophrenia: 10%

Mood Disorder: 9%

ADHD: 8%

Most common across Health Home (n=1878)

Schizophrenia 33%

Depression: 27%

Bipolar: 13%

Mood Disorder: 12%

Adjustment D/o: 7%

TPC Primary Diagnoses


Goals of models

Goals of models

Behavioral Health within

Primary Care Setting

Increase awareness of behavioral health care issues for both provider and patient

Increase access to

behavioral health

screening and intervention

Improve chronic disease management


Behavioral health within pc

Behavioral health within PC

  • Part-time psychologist

    at largest PCHC site

  • Specially trained in integrated care within a primary care setting

  • Referrals comprised of a combination of traditional mental health and chronic disease lifestyle management

  • Model based on 30-minute triage/CBT interventions averaging 3-6 visits per patient, mostly triage and referral


Behavioral health within pc1

Behavioral health within PC

Providence Community Health Centers at Prairie Avenue Collaboration

Outpatient child and adult practice embedded within PCHC with bilingual therapist and bilingual child/adult psychiatrist

New Health Home currently piloting


Diagnostic rankings

Diagnostic Rankings

Top three behavioral health

diagnoses within FQHC (PCHC @ Prairie)

Male & Female > 18 y/o

  • Depressive Disorder NOS

  • Recurrent Depression

  • Anxiety Disorder NOS

Top three physical health diagnoses within embedded medical center of CMHC (PCHC @ NM)

Male & Female > 18 y/o

  • Diabetes, Type 2

    2. Hyperlipidemia

    3. Hypertension


Goals of models1

Goals of models

Primary Care within

Mental Health Setting

Improve morbidity and mortality of consumers with mental illness and addictions

Decrease barriers to access to physical health care for consumers with behavioral health issues

Improve health literacy for both providers and clients


Primary care in behavioral health

Primary care in behavioral health

Providence Community Health Centers at North Main Street

Opened June 2011

Physician, nurse, medical assistant & health centerdirector

TPC-employed integrated care manager with a health literacy focus


We are partners in health

“We are partners in health.”

“We treat complex patients who have complex problems, many of whom have not sought health care for a long time. I talk with my patients about about understanding what they have to do to get healthy and how I can support them.”

-Dr. Tariq Malik, M.D., M.P.H., primary care physician at Providence Community Health Centers at North Main


Integrated care at the providence center 2014

Personal trainers who are also trained case managers

Individualized fitness and healthy lifestyle assessment performed by the health mentor for every participant

Fitness plan, including eating, exercise, and health promotion

Weekly individual meetings with a health mentor to participate in fitness activities from walking to gym attendance

  • Assistance with access to fitness resources

  • Opportunities for group exercise and healthy eating education


Primary care in behavioral health1

Primary care in behavioral health

SAMHSA funded PBHCI Grant

  • Awarded in 2010, 4 year grant

  • Emphasis placed on embedding medical nurse care managers in Home Health SPMI Teams

  • Education and triage related to management of chronic disease, greater access to primary care

  • PHQ9, AUDIT, Stanford Self-Efficacy, Self-Rated Abilities for Health Practices and SF-36 administered

  • Baseline, then every 3 months until one year completion, physical health measures including, BMI, Weight Loss, Blood Pressure, HbA1c, HDL, LDL and Triglycerides


Pbhci results

PBHCI Results

Hospitalization Utilization

Psych hospitalization and psych ER use significantly decreased

Medical hospitalizations and medical ER visits increased.

All types of hospitalizations showed a net decrease (156 days less net)


Cost savings n 350

Psych Hospitalization

428 days to 256 days = $122,120 savings

National average $710 per day2

Psych ER

72 times to 33 times = $27,300 savings

National average $700 per day1

SU Hospitalization

49 days to 24 days = $24,250 savings

National average $970 per day2

TOTAL

$173,670 savings for 350 individuals designated as SPMI

Cost Savings (n=350)


Integrated care at the providence center 2014

PBHCI Results

Self-Efficacy (Stanford)

Clients belief that they can communicate with physicians,

manage disease in general, manage symptoms of disease, increase nutritional abilities, improve psychological well-being

has significantly improved over one year with nurse care coordination.


Pbhci results1

Physical Health Measures

Statistically significant improvements over the course of one

year in the below lab values

Drawbacks: lab data difficult to obtain and as a result n quite small

PBHCI Results


Pbhci results2

Subjective Health (SF-36)

Every aspect of health perceived to have statistically significantly improved over the course of the year, except bodily pain and health perception.

PBHCI Results


Pbhci results3

PBHCI Results

If alcohol screening (AUDIT) initially at-risk (>8) AT BASELINE, there was a statistically significant decrease in risk after one year of nurse care management participation

  • Mean scores from 15.35 to 9.43 to 9.65. This is a significant decrease at p<.001. (n=40 to 23 to 20)

If depression screening (PHQ-9) initially in the moderate range (>10) AT BASELINE (n=158), there was a statistically significant reduction over the course of one year.

  • Mean: 16.15 to 12.17 to 10.72 (p<.001)


Pbhci results bmi

Weight change descriptives for BMI>30 at baseline:

PBHCI Results: BMI

  • BMI (200 to 152 to 186): 38.5 to 37.1 to 36.9 (p=.003)


Integrated care at the providence center 2014

Integrated care coordinator meets with SPMI (Health Home) patient a few minutes prior to physician entering the room to:

assist pt in focusing on the top 3 issues he/she would like addressed today

review logistics of PC: prepare pt about length of appt, any longer than anticipated wait times, etc.

review pt’s mood, new stressors and any emotional issues that could be impacting physical health

At the same time, physician reviews an interagency form:

includes pt’s mental health diagnoses, psychiatric medications and any relevant notes from mental health team

Health Literacy: Before the Medical Visit


Integrated care at the providence center 2014

Integrated care coordinator stays with pt for the length of exam to:

be a witness to the points of difficulty between pt and physician

provide support to the physician should the pt experience difficulty communicating

provide support to the pt should pt experience difficulty understanding medical concepts or recommendations

Health Literacy: During the Medical Visit


Health literacy after the medical visit

Health Literacy: After the medical visit


Bottom line

Bottom Line

  • Integrated care must be infused into the core mission, values and commitment of an organization to be successful.

  • There is no right way to integrate, but there are known strategies that are evidence-based

  • Addressing the integrated care needs of the SPMI population is a challenge, but is no longer optional.


Citations

Citations

  • Stranges, E. (Thomson Reuters), Levit, K. (Thomson Reuters), Stocks, C. (Agency for Healthcare Research and Quality) and Santora, P. (Substance Abuse and Mental Health Services Administration). State Variation in Inpatient Hospitalizations for Mental Health and Substance Abuse Conditions, 20022008. HCUP Statistical Brief #117. June 2011. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb117.pdf

  • Russo, C. A. (Thomson Healthcare), Hambrick, M. M. (AHRQ), and Owens, P. L. (AHRQ). Hospital Stays Related to Depression, 2005. HCUP Statistical Brief #40. November 2007. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb40.pdf


Contact information

Contact Information

Nelly Burdette, PsyD

Director of Integrated Care

The Providence Center

530 North Main St

Providence, RI 02904

Direct Office: 401/415-8820

Email: [email protected]


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