Integrated Primary Care Practice in a Federally Qualified Health Center: Moving Forward

1. Session # Track H4a October 29, 201110:30 AM Integrated Primary Care Practice in a Federally Qualified Health Center: Moving Forward Andrea Auxier, Ph.D. Director of Integrated Services and Clinical Training Katrin Seifert, Psy.D. Associate Psychology Training Director Salud Family Health Centers, Colorado Collaborative Family Healthcare Association 13th Annual Conference October 27-29, 2011 Philadelphia, Pennsylvania U.S.A.

2. Faculty Disclosure We have not had any relevant financial relationships during the past 12 months.

3. Need/Practice Gap & Supporting Resources In a progressively complex and fragmented healthcare system and in response to the need to provide whole-person, quality care to greater numbers of patients than ever before, primary care practices throughout the country have turned their attention and efforts to integrating behavioral health into their standard service-delivery models.  With few resources and little guidance, systems struggle to gather the support required to establish effective integrated programs. Based on first-hand experience, we describe the development of a working integrated primary care model being utilized in in a large community health center system in Colorado. 

4. Objectives • Identify practice-specific and system-specific factors to consider when setting up an integrated practice • Describe how practice-based research can inform service-delivery and organizational protocols • Describe how a focus on training can be leveraged both financially and clinically • Identify a population-based model of integrated care being utilized in a large FQHC system

5. Expected Outcome The purpose of the talk is to provide participants with a broad range of considerations to utilize when establishing integrated practices.

6. In 2008, mental health conditions accounted for $72 billion in expenditures, making them the third most costly condition (along with cancer), exceeded only by heart conditions and trauma-related disorders. (AHRQ 2008) 75% percent of total health care spending in 2007 went towards the treatment of chronic diseases, such as diabetes and asthma. (CMS) Healthcare costs are rising 6% a year.(Source: Congressional Budget Office) The cost of doing something that may work is less than the cost of continuing to do something that definitely won’t.

7. Why are we in such a pickle? Divided systems breed divided practice

8. Payment • Carved out systems • Fee for service vs. capitation • We’ll pay you to do it there, but not there

9. Recommendations 1) Create New Departments Behavioral health Data management EHR design Policies, Procedures, and Training • Put people in charge of them • Talk to each other! • Balance executive decisions with democratic processes • Dispense with the silos

10. Diffusion of responsibility • Duplication of efforts • Inefficient processes • Unspoken expectations become breeding grounds for resentment

11. Dispensing with the Silos A necessary integration of previously divided sections of the organization Dental Medical Human Resources Behavioral Client Services Education Administrative Services Development Reporting Accounting & Finance Information Technology Facilities Management

12. The Old Way

13. The New Way Care Coordination Self Management Goals Referral Tracking Proactive Management of Targeted Patients (e.g., asthma, depression, COPD, narcotics) Visit Summaries Collaborative Treatment Planning

14. THE SALUD STORY Idea to Implementation FORT LUPTON 1970 FREDERICK 1978 MOBILE UNIT 1979 BRIGHTON 1980 COMMERCE CITY 1986 LONGMONT 1979 FT. COLLINS 2002 STERLING 2001 ESTES PARK 1992 FT. MORGAN 1994

15. What is an FQHC? MUA/MUP

18. Challenges • Many patients, not so much money • Turf issues • Common goals vs. competing objecting objectives • Internally • Externally

19. Team Composition 19 FTE Behavioral Health - 7 Psychology Postdoctoral Fellows

20. Collaboration • Put it in writing! • Make expectations explicit. • Define reporting relationships

21. Collaboration Requirements • Are, at minimum, master’s level clinicians licensed in the state of CO • Are at least half time (.5FTE) • Adhere to Salud’s integrated care model • Do not discriminate by payer source or patient’s county of residence • Are part of the behavioral health department; attend departmental meetings • Are credentialed through Salud human resources prior to start date • Document patient encounters in Salud EMR only • Bill for patient encounters utilizing Salud Standard Operating Procedures for behavioral health billing. Certain types of co-payments and third-party reimbursements can be collected by partner agency if agreed to and documented in a Memorandum of Understanding signed by both parties. • Report to the Director of Integrated Services & Clinical Training • Are subject to formal evaluation processes

22. Larimer Center Estes Park .5FTE Centennial Sterling Ft. Collins 5 FTE 2 PT psychiatrists Health District Ft. Morgan 1 PT psychiatrist Longmont 2 FTE 1 PT psychiatrist North Range BH Mental Health Partners Frederick 1 FTE Ft. Lupton 2 FTE 1 Case Manager Brighton 2 FTE Non-Clinical Positions Director of Integrated Services 1FTE Associate Psychology Training Director 1FTE Commerce City 2 FTE

23. Early Considerations • Who are the patients? • What do they need? • What resources are there in the community? • When will we refer, and for what reasons? • Will the patients go? • Will they get in? • What will we do if they come back?

24. Service-Delivery BHP Initiated Screening PCP Initiated Consultation, Evaluation, & Brief Interventions Patient Initiated Therapy A completely integrated primary care system that provides quality population-based care through improved access

25. Adult Screening to Treatment Protocol Referral to MHC/ Specialty Service Referral to MHC/ Specialty Service

26. What we Know • Depression: 35% • Anxiety: 35% • Trauma: 13% • Alcohol: 10% • Substances: 4% • Smoking: 30% • Safety of Living Environment: 2%

27. What it Means It’s not just about depression Disease-specific models are for people with specific diseases treated in systems that can accommodate disease-specific models

28. Workforce Development Imagining a world without BHPs Comparative Effectiveness Research Scalable Architecture for Federated Translational Inquiries Network Leveraging the power of the mission statement Looking down the Road Medical Home & ACOs How we Pay for It Patient Revenue Copayments for therapy and testing

29. Workarounds or Solutions?

30. Successes • Staffing on a shoestring budget • A standardized service-delivery model • Behavioral health woven into the organizational fabric • Clinical Training Program • Relationships with outside agencies moving in positive directions • 14,000 patients served/yr • Integration of comparative effectiveness research efforts

31. Lessons Learned Embrace the good enough principle Do vs. think about doing whenever possible Process informs evolution Strategies trump models Build the infrastructure to support the idea Do what we can to do today to help us build the case for doing it tomorrow Foster relationships – at ALL levels Always look down the road (PCMH, ACO) Be patient: Transformational change takes time Remember What it’s Really About Meaningful use of meaningful measures

32. September 2010 Goals • Increase size of BH team • Expand training program • Increase health psychology services • Expand service delivery (child, addiction) • Research

33. Directions • Promote clinically meaningful and organizationally feasible research • Hire people to do what they’re trained (and love) to do • Emphasize continuous quality improvement • Never stop growing!

34. Learning Assessment 1) According to the Congressional Budget Office, healthcare costs in the Unites States are rising at a rate of what percent per year?: a) 3% b) 6% c) 9% d) 12% 2) What percentage of an FQHC’s board must be comprised of patients? a) 0% b) 10% c) 50% d) more than 50% 3) Which of the following is NOT a standardized screening tool a) PHQ-9 b) PCL c) PDI d) DAST

35. Session Evaluation Please complete and return theevaluation form to the classroom monitor before leaving this session. Thank you!