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“Enhanced Wellness” Integration of Behavioral Health Services into Primary Care. Tom Ewing, M.D. CMO and EVP PacificSource Health Plans OCHCP Annual Conference December 6, 2012. PacificSource Community Health Excellence Grants. Community Health Excellence Grants. Enhanced Wellness.

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“Enhanced Wellness”Integration of Behavioral Health Services

into Primary Care

Tom Ewing, M.D.


PacificSource Health Plans

OCHCP Annual Conference

December 6, 2012


Enhanced Wellness

The Model

  • Successful projects around the country in integrative care, including the Minnesota, Institute for Clinical Systems Improvement, DIAMOND Project
  • “Diabetes Improvement Across Minnesota Offering a New Direction”
  • Additive to evolving PHMG Medical Home

Enhanced Wellness

Our Project

  • Embed behavioral health clinicians in primary care
  • Depressed, diabetic patients seen by PeaceHealth Family Doctors
  • Started with Dr. Steven Yoder, PeaceHealth Family Medicine, and his Medical Assistant, Shawna
  • Expanded to include 25 additional PCP’s and Nurse Practitioners
  • Help these patients to improve their depression symptoms faster
  • If more attention is paid to their depression, then medical conditions (diabetes) improve as well
  • Metrics: PHQ9, HbA1C, PAM, patient satisfaction, provider satisfaction
  • Jacque and Tara on site, patient contacts face to face, and by phone
  • Psychiatrist consults with Jacque, Tara, and PCPs

Enhanced Wellness

Intervention and Activity

  • Phone counseling
  • Referral for counseling or other resources
  • Telephone coaching
  • Chart review with PCP follow up
  • Psychiatric medication consult
  • Chart review with wellness coordinator follow up

Enhanced Wellness

Parallel Projects within PeaceHealth

  • Team Fillingame – Medical Home Innovation site
  • PeaceHealth High Value PCC, RN Care Managers
  • PeaceHealth Lean - “All in One” and Flow Stations
Project Director and Consulting Psychiatrist: Robert Brasted, MD

Care Manager: Jacque Travis, MEd

Medical Office Assistant: Tara Walker

Behavioral Health Outpatient Director: Terry Stimac, PhD

Chief Adult and Family Medicine: Jill Chaplin, MD

PacificSource Case Management: Barb Healy, RN

PHMG Director of Quality: (Mary Minniti)

System Manager planned Care/Medical Home: David Killaby

Ad hoc, from around PeaceHealth and in the community:

Michael Ray, data analyst

Rowena Thornton, Performance Improvement Facilitator

Denise Butler, Program Manager, PeaceHealth Planned Care

Bobbie Picolet, Clinic Manager, Adult Family Medicine

Shannon Walker, Family Medicine Clinic Admin

Sherry Catlin, DO Regional VP Medical Affairs (Florence)

Steve Allen, PhD. CEO Options Counseling

Enhanced Wellness

The Team


Enhanced Wellness

Year 1 Summary

  • Primary Care serves many patients with mental and behavioral disorders
  • Improve access to Behavioral Health Services for primary care. Started with 1 family docs depressed/diabetic patients
  • Masters level therapist-Care Manager (Jacque) and Psych Medical Office Assistant (Tara) provide patient contacts on site in Family Medicine and by phone

Enhanced Wellness

Year 1 Summary Continued

  • Care Manager/MOA available to PCP/nursing staff for rapid referrals, frequent as needed follow ups
  • Dr. Brasted consults with Care Manager/MOA and PCPs regarding diagnosis, treatment, and medications
  • Much communication via EMR
  • Assist depression to improve faster, diabetes to stabilize
  • Metrics: PHQ9, HbA1C
  • Many Behavioral Health consults/screenings beyond depression and diabetes

Enhanced Wellness

Year 2 Project. Goes Viral.

  • Spread to all PHMG UD Family Medicine Clinic providers
  • Services also accessed by PeaceHealth PCP providers outside the UD
    • RoszeBarrington,DNP John Holtzapple,MD
    • MariquitaBelen,MD Barry Jarvis,MD
    • KlarissaBeller,MD Michael Laurie,MD
    • Angela Bradley,FNP Eric Lester,PA-C
    • Michael Carnevale,DO John Merrick,MD
    • Jill Chaplin, MD William Moshofsky,MD
    • Christa Danielson,MD Aaron Pardini,MD
    • Sidney Davidson,MDJanjanReforma,MD
    • Jennifer DiFrancesco,FNPGulrukhRizvi,MD
    • Juanita Doerksen,MD Andrei San-Marina,MD
    • Ralph Fillingame,MD Julia Sunkomat,MD
    • Mary Gabriele,MD Tara Workman,MD
    • Larry Hirons,MD Steven Yoder,MD

Enhanced Wellness

Year 2 Project Continued

  • Explosion of previous interest and initiatives in Medical Home and care integration
  • CCO development – aligns with OHA PCMH
  • Blending of PeaceHealth’s parallel projects
    • Team Fillingame
    • High Value PCC - Care Management
    • “All in One” primary care team model
  • Team expanded to include
    • PeaceHealth “Network” partners, Florence
    • PeaceHealth Network and system admin staff from Planned Care and Case Management
    • Community partners: Options Counseling

Enhanced Wellness


  • 151 patients had multiple PHQ9’s
  • 103 (68.2%) had lower PHQ9’s (p<.01) after intervention compared to 40(26.5%) who had higher PHQ9’s and 12(8%) who showed no change
  • 91 patients had multiple HBAIC’s
  • 58(63.7%) had lower AIC’s (p<.01) compared to 25(27.5%) who had higher AIC’s and 2(.02%) who showed no change
  • 39 patients who had one or more interventions had multiple PHQ9’s and multiple AIC’s
  • 18(46.2%) had both lower PHQ9’s and AIC’s(p<.01)
  • 2(1%) had both higher PHQ9’s and AIC’s

Enhanced Wellness

Learnings From Year 2

  • Still helpful to have experienced Care Manager/therapist
  • MOA trained successfully at assuming many Care Management functions
  • EMR vital
  • Increased Behavioral Health presence in Primary Care improves patients depression and diabetes, as well as assisting to triage, care for variety of behavioral, mental, drug/alcohol conditions
  • Sustainability is possible (no longer a question)
    • PeaceHealth Medical Home Council
    • Working out FTEs, job descriptions for Care Manager/Behavioral Health specialist for every team
  • FPs enthusiastic
  • Challenge: depressed, diabetic patients hard to get in for their visits

Enhanced Wellness

Toward the Future

  • Team continue to meet, inform PHMG Medical Home development
  • More patients, more difficult/unwell patients can have improved health outcomes with more frequent follow up
  • Inform wider community care integration initiatives
  • Expand on data regarding ED, urgent care, hospitalization rates
  • Inform CCO development
  • Financial sustainability