Clinical Issues in Outpatient Services: Re-tooling of Models Bea Dixon

1. Clinical Issues in Outpatient Services: Re-tooling of Models Bea Dixon Examining new or different models of providing outpatient services, including review of best and/or promising practices

2. We are not unlike these would-be aviators of earlier times. What components in our service delivery could give our clients more “lift”? What makes it possible for our clients to “fly”?

3. Primary Care/Behavioral Healthcare Integration: exciting opportunities! Person-centered healthcare home: Medical Home: PCP PCP & Behavioral Health Specialist Close collaboration and coordination between person-centered home and CBHO With stepped care option

4. Our Goal: To offer service opportunities to persons with behavioral issues to pursue optimal health, happiness, recovery, and a full and satisfying life in the community via access to a range of effective services, supports, and resources. Our Task: To transform a system that is essentially fragmented and reactive, to one that is integrated and proactive, by: • Creating a collaborative continuum between PCP, mental health and substance use providers; • 2) Retooling our clinical approach and processes.

5. Task 1: Creating a collaborative continuum between PCP, mental health and substance use provider.

6. Person-Centered Healthcare Homes Principles: • Ongoing relationship with a PCP • Care team who collectively take responsibility for ongoing care • Provides all healthcare or makesappropriate referrals • Care is coordinated and/or integrated • Quality and safety are hallmark • Enhanced access to care is available • Payment appropriately recognizes the added value

7. From a client’s perspective “I receive exactly the care I want and need, exactly when and how I want and need it.” • Access, coordination, practice efficiency: • “I have one person I think of as my personal doctor.” • “The members of my care team work well together.” • “They coordinate the services I receive from other providers.” • “They are well organized, efficient, and do not waste my time.” • 24/7 accountability: • “It is very easy for me to get care when I need it.” • A partnership approach with the care team: • “They ask for my ideas.” • “They give choices of treatment to think about.” • “They ask me about my goals in caring for my condition.” • “I am sure that they know my values, beliefs, and traditions.” Patient Assessment of Chronic Illness Care www.improvingchroniccare.org

8. A system of care that organizes itself Who What Where When How Behavioral complexity (MH/SU) Medical complexity

9. Helping Consumers Find the Right Healthcare Home

10. Integration Policy Initiative

11. Assignment of client populations: Behavioral health dimension Low:V-codes, mild depression, mild anxiety, sleep disorder, somatic disorder, SU disorder Moderate: Moderate depression, moderate anxiety (including PTSD), sleep disorder, somatic disorder, SU disorder (abuse) ? Severe: Severe depression, severe anxiety (including PTSD), schizophrenia, bipolar disorder, schizoaffective disorder, personality disorders, SU disorder (abuse/dependence) Serious: Schizophrenia, schizoaffective disorder, bipolar disorder, SU disorder (abuse/dependence)

12. Your current PCP services: With proper support, could they serve additional client populations? Your current outpatient services: Do you have client populations that could be served in primary care? How many of your staff could be stationed at a PCP office? Your rehabilitation services: Do you have client populations that could be served in primary care?

13. Assignment of client populations: BH and Medical dimensions

19. Healthcare Homes for SMI Adults Question: Can a typical Primary Care Clinic serve as a successful holding environment for adults with Serious Mental Illness? Primary Care Services embedded in a CBHO is an important strategy for addressing the health disparities for the SMI population.

20. Task 2: Retooling our clinical approach and skills.

21. Good outcomes (clinical, satisfaction, cost, and function) result from productive interactions. To have productive interactions the system needs to develop four areas at the level of the practice: Chronic Care Model a. Delivery system design: Who is on the health care team and how do we coordinate our clients’ care? b. Clinical decision support: What is the best care and how do we make it happen every time? c. Self-care management: How do we help clients live with their conditions? d. Clinical information systems: How do we capture & use critical information to improve clinical care? E. Wagner, Group Health

23. IMPACT program – Doubling the effectiveness of usual care for depression. How was this achieved? One home with stepped care option Person-Centered Home Delivery system Decision-support Self-management Clinical information system • Application of elements of the Chronic Care Model: • Collaboration and coordination: • A care team consisting of a PCP and • Behavioral Health Specialist/Care Coordinator, in consultation with psychiatrist when needed. • Clinical guidelines and evidence-based practices are embedded in daily • practice: • Use of screening tools, flow sheets as reminders, and • standardized intervention modules • Self-management training opportunities, • Education, joint decision making • A robust online client tracking system/registries to ensure better clinical outcomes, reduce medical costs and waste.

24. Example of a service approach Behavioral health services in primary care settings Person-centered Delivery design system Clinical decision support Self-management Clinical information system Proposed Flow: The patient's primary care physician works with a care coordinator to develop and implement a treatment plan (medications and/or brief, evidence-based therapy). Care coordinator and primary care providers consult with a designated prescriber when needed. Cont’d

25. Care Coordinator (nurse, social worker or psychologist): • Educates the patient about mental health conditions; • Supports psychiatric medication therapy prescribed by the • patient's primary care provider if appropriate; • Coaches patients using Behavioral Activation, Motivational • Interviewing ,or other relevant counseling techniques; • Offers a brief (six-eight session) course of evidence-based • counseling, such as Problem-Solving treatment (PST) or Cognitive • Behavioral Therapy; • Monitors symptoms for treatment response; • Completes a relapse prevention plan with each patient who has • improved; Cont’d

26. Psychiatrist consults with the care coordinator and primary care physician on the care of patients who do not respond to treatments as expected. The Care coordinator measures symptoms at the start of a patient's treatment and regularly thereafter using brief, structured screening and clinical rating scales that are appropriate for the specific disorders that are being treated. (PHQ-9 (for depression), GAD-7 (for anxiety disorders), GAIN-SS (GAIN SDScr) (for chemical dependency) • Stepped care: • Treatment is adjusted based on clinical outcomes and according to evidence • based treatment algorithms and principles • Aim for a 50 percent reduction in symptoms within 10-12 weeks • If client is not significantly improved at 10-12 weeks after the start of a • treatment plan, change the plan (increase of medication dosage, a change to a • different medication, addition or change of psychotherapy, a combination of • medication and psychotherapy, or other treatments suggested by the team • psychiatrist). The IT system contains rating scales/screening tools that enable care coordinators to track and monitor clinical improvement.

27. Washington State GA-U Project Clinical Flow

28. Physical health monitoring of SMI clients: 1. Assure regular screening and tracking at the time of psychiatric visits for all behavioral health consumers receiving psychotropic medications—check glucose and lipid levels, blood pressure, weight ,and Body Mass Index (BMI). 2. Record and track changes and response to treatment and use the information to obtain and adjust treatment accordingly.

29. Example of a service approach Services in CBHOs (for moderate to severe client populations) Care Team and care coordination • Evidence-based treatment – with decision support: • Cognitive Behavior Therapy • (depression, anxiety) • Motivational Interviewing • Dialectic Behavioral Therapy • Trauma therapy Person-centered Delivery design system Clinical decision support Self-management Clinical information system Outcome-based: Validated assessment tools: pre- and post • Self-management support Referral, with coordination of care, to primary care, level I S/U outpatient services (including ambulatory detoxification), medication assisted treatment. Clinical Information System (registry system) Stepped Care

30. Example of a service approach Services in CBHOs (for severe to serious client populations) • Care Team and care coordination • Evidence-based treatment – with decision support: • Cognitive Behavior Therapy for psychosis • Motivational Interviewing • Co-occurring disorder treatment • PACT • Recovery coaching • Family psycho-education • Supported education • Supported employment • Supported housing • Trauma therapy • Outcome-based: Validated assessment tools: pre- and post Person-centered Delivery design system Clinical decision support Self-management Clinical information system Cont’d

31. Self-management support: • Illness self-management (an evidence based program) • Peer Support • Peer-run programs, i.e. Clubhouse • Referral, with coordination of care, to primary care, level I S/U outpatient services (including ambulatory detoxification), medication assisted treatment. • Clinical Information System (registry system) • Stepped Care

32. Physical health monitoring: 1. Assure regular screening and tracking at the time of psychiatric visits for all behavioral health consumers receiving psychotropic medications—check glucose and lipid levels, blood pressure, weight ,and Body Mass Index (BMI). 2. Record and track changes and response to treatment and use the information to obtain and adjust treatment accordingly. 3. Medical nurse practitioners/ primary care physicians located in behavioral health. 4. A primary care supervising physician. 5. An embedded nurse care manager. 6. Identify the current primary care provider for each individual and assure coordination. 7. Provide education. 8. Wellness programs.

33. Possible challenges experienced by clinical staff Forming a care team versus working in silos Coordinating care Incorporating evidence-based practices, creating and using standardized work modules: • We’ve always done it this way. Why change? • It will replace my clinical judgment. • I don’t have time for it. • It will lead to “cookbook practice.” • It’s too difficult. • Basing treatment on clinical outcomes and according to evidence based treatment algorithms and principles. Cont’d

34. Possible challenges (cont’d) Moving into a role of shared expertise with the client At least 50% of clients leave the office without understanding what they were told. Participatory decision making occurs in about 25% of office visits. Creating an IT system that contains rating scales/screening tools and enables care coordinators to track and monitor clinical improvement.

35. Summary • Primary Care/Behavioral Healthcare Integration presents exciting opportunities: • Transforming a system that is essentially fragmented and reactive, to one that is integrated and proactive, by: • Establishing a collaborative continuum between PCP, mental health and substance use providers: • Person-Centered Healthcare Home • Retooling our clinical skills and processes: • IMPACT • Chronic Care Model • Various applications in PCP and BHCO practices

36. Questions or Comments?