integrated care a mehaf project n.
Skip this Video
Download Presentation
Integrated Care: A MeHAF Project

Loading in 2 Seconds...

play fullscreen
1 / 37

Integrated Care: A MeHAF Project - PowerPoint PPT Presentation

  • Uploaded on

Integrated Care: A MeHAF Project. WHEN THE HEAD IS ATTACHED TO THE REST OF THE BODY Kathleen L. Webster RN, MSN PMHNP-BC. MEHAF GRANT. MaineGeneral ACT TEAM selected to participate in a 3 year Grant funded project with the Maine Health Access Foundation (MEHAF) MEHAF’s Mission:

I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
Download Presentation

PowerPoint Slideshow about 'Integrated Care: A MeHAF Project' - nasim-barron

Download Now An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.

- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
integrated care a mehaf project

Integrated Care:A MeHAF Project


Kathleen L. Webster RN, MSN PMHNP-BC

mehaf grant
  • MaineGeneral ACT TEAM selected to participate in a 3 year Grant funded project with the Maine Health Access Foundation (MEHAF)
  • MEHAF’s Mission:
  • Promote affordable and timely access to comprehensive, quality health care
  • Improve the health of Maine residence
mehaf grant1
  • Systems transformation grant
  • Jan 1/09-Dec/11
  • ACT TEAM one of 6 community agencies selected
  • Focus of grant-consumers with DX of SMI in addition to diabetes or metabolic syndrome
6 community agencies
6 Community Agencies
  • Common Ties
  • Crisis and Counseling
  • Kennebec Behavioral Health
  • MaineGeneral ACT TEAM
  • Motivational Services
  • Tri-County ACT TEAM
mehaf grant2
  • Key Objectives:
    • Link consumers to PCP
    • Care Management for consumers with SMI and chronic medical diseases
    • Peer Support systems enhanced or developed
    • Develop screening tools
    • Develop Tracking systems for clinical workflow
    • Training and education for both consumers and providers
    • Communicate and collaborate with policy makers
mainegeneral act team members
Amy McKenna

Debbie McGuire

Marc Gallant

Susie Carlsen

Jane Cloutier

Renee Quirion

Georgette Roy

Sheila Worth

Heidi Little

Stacie Dennett

Kathleen Webster

MaineGeneral ACT Team Members
  • Emilie Van Eeghen
  • Barbara Crowley
  • James Schneid
  • Nancy Weingarten
  • Susan Albano
  • Jessica Ruth
  • Louise Gephart
  • Nina Miller
  • Louisa Barnhart
  • Maria Beauregard
target population
Target Population
  • MaineGeneral ACT Team

93-100 persons who are cared for by the ACT team in Augusta and Waterville participated in this grant project over a 3 year period.

ACT team clients by definition have a severe and persistent mental illness as well as co-morbid substance use disorders and chronic medical illnesses.

significance of clinical problem
Significance of Clinical problem
  • People with SMI die 25 years earlier than people without SMI
  • Average age of 53 years old
  • A Maine Study of Medicaid Recipients revealed 87% of lives lost to premature death are not due to suicide but rather chronic medical conditions Maine CDC 2004
diabetes smi mainecare
Diabetes & SMI- MaineCare

SMI -$5,360

  • NON – $3,930
  • Double the prevalence
  • High risk – Smoking, Obesity, dyslipidemia
  • Less Access to a medical home
  • Poorer Outcomes

Maine CDC 2004

body mind spirit
  • Hypertension
  • Diabetes
  • Obesity
  • Cardiovascular Disease
  • Access to primary and specialty care often hampered
  • Poverty
  • Substance Use/Dependence inclusive of nicotine
  • Poor Nutrition
  • Inadequate exercise
  • Exposure to psychotropic medications
  • Stigma
  • Socially marginalized
  • Support System often limited to care providers
  • Disconnect between mental health and physical health care systems
iom 6 aims for improvement
  • SAFE
                • IOM, 2001
iom 10 rules for redesign
  • Care is based on continuous healing relationships
  • Care is Customized to patient needs & values
  • Patient is the source of control
  • Knowledge is shared & information flows freely
  • Decision making is evidence based
  • Safety is a system property
  • Transparency is necessary
  • Needs are anticipated
  • Waste is continuously decreased
  • Cooperation among clinicians is a priority
            • IOM, 2001
iom 4 areas of redesign
IOM:4 Areas of Redesign
  • Evidence Based Care
  • Utilization of Information Technology
  • Aligning Payment Policies with QI
  • Preparing the Workforce
                  • IOM, 2001
act team
ACT Team
  • MaineGeneral ACT Team

Approximately 93-100 persons who are cared for by the ACT team in Augusta and Waterville participated in this grant project over a 3 year period.


A Run Chart was utilized to study one outcome related to ED usage.

Time studied was 12/09-11/11 representing 24 data points representing time.

The Number of ED visits by ACT team clients per month was manually counted and plotted against the time variant.

data analysis interpretation
Data: Analysis & Interpretation
  • Test #1 Presence of too much or too little variable
  • There are 24 data points, excluding 1 point on the median, in which there are 9 runs. The probability table shows that with 24 points at least 8 runs are needed and no more than 17 therefore no special causes are present only common cause.
  • Test #2 Presence of a shift in the process
  • There are no runs with more than 4 data points, at least 8 are necessary to demonstrate a shift in the process therefore common cause only present
  • Test #3
  • No evidence of a trend as there are no more than 4 consecutive data points
data analysis interpretation1
Data: Analysis & Interpretation
  • Common Cause Variation in the number of ED visits.
  • This number of visits is worthy of a change process for improvement
  • NOTE addition of 4 hours per week of FNP starting in July with an increase in communication and expectation of collaboration between the ACT team clinical/support staff and the PCP clinical and support staff.
chronic care model
Chronic Care Model
  • Community
    • Resources and Policies
  • Health System
    • Self Management
    • Delivery System Design
    • Decision Support
    • Clinical Information Systems
  • Productive Interactions
    • Informed, Activated Patient
    • Prepared, Proactive Practice Team
  • Outcomes
    • Improved Outcomes
safe avoid injuries to patients from the care that is intended to help them
Safe: Avoid injuries to patients from the care that is intended to help them

Treatment Evidence Based

Labs as per recommended protocols

F/U w/ Psych Providers- Case Managers

F/U w/ Medical Providers- Case Managers

Avoid ED utilization as an intervention for Primary care needs – Access to PCP key

Effective: Provideservices based on scientific knowledge to those who would benefit - refrain from those not likely to …..
  • One goal - to develop ways to track health issues and workflow
    • Development of a Screening Tool
    • Request report from MaineGeneral system related to ED visits
PATIENT CENTERED: Respectful and responsive to individual needs/values that guide the careThe 4 Quadrant Clinical Integration Model

Quadrant I BH PH

Quadrant III BH PH

>PCP (screening tools/BH practice guidelines)

>PCP based BH consultant/care manager

>Specialty Med/Surg

>Psychiatric consultation


>Med/Surg Inpatient

>Nursing Home/Home based care

>Community Resources 2010

>PCP (screening tools & BH practice guidelines)

>PCP based BH consultant/care manager

>Psychiatric Consultation

4 quadrant clinical integration model
4 Quadrant Clinical Integration Model

Quadrant IV


Quadrant II


>BH Clinician/CM coordinating with PCP

>PCP (Screening tools/guidelines)

>Outstationed medical provider at BH site

>Specialty BH

>Residential BH


>BH Inpatient

>Community Supports 2010

>PCP (screening tools / guidelines)

>Outstationed medical provider in the BH site

>BH Clinician/case manager

>External Care Manger

>Specialty med/surg

>Specialty BH

>Residential BH


BH/Med/Surg Inpatient

>Community Supports

timely and efficient
Timely and Efficient

Tracking of consumers who access ED to notify provider in real time.

Linking the screening tool to Clinical support tools

Consumer Access of training options

System that would notify team of pertinent thresholds



latest f/u per treatment guidelines

Diabetes Screening and Treatment

Recommended Labs

eye exams

foot exams

Equitable: care that does not vary in quality due to gender, ethnicity, geographic location, socioeconomic status

Linking consumer to a welcoming PCP one of the primary intents of the MeHAF project.

  • At the end of the 3 year project
    • 100% of clients reported having a PCP
    • 80% reported having seen PCP in past year
    • 69% reported ED visit
health screen
Health Screen
  • Developed in the Second Year of the Project
  • Has increased the dialogues between team members, both clients and staff.
  • Has established some baseline data that is now informing the practice in the office.
  • Has created an opportunity for improved care outcomes
  • Has created an opportunity for integrated care concepts
health screen1
Health Screen
  • Of 81 clients surveyed in the past 2 years
    • 53% have 5 or more co-morbid medical illnesses
    • 15% have 4
    • 14% have 3
    • 11% have 2
    • 7% have 1
    • 2% have none documented
    • 4 people have passed away in the past 15 months
health screen2
Health Screen
  • In the first 12 months
  • 69 clients screened
  • 59% had BMIs > 25
  • 38% had BP > 130/80
  • 96% had a PCP
  • 86% seen in past 12 months
  • 44% seen in the ED for both mental health and medical care
  • The following 9 months
  • 64 clients screened
  • 61% had BMIs >25
  • 25% had BP> 130/80
  • 100% had a PCP
  • 80% seen in past 12 months
  • 69% seen in the ED for both mental health and medical care
take away
Take Away
  • The dialogue with the client regarding their physical as well as mental health concerns increased in frequency and structure
  • A richer base for patient education was established
  • An increase in collaborative dialogues with health care providers in the community who are also caring for the ACT client
  • An opportunity to have an FNP 4 hours per week in the ACT team office as a result of dialogues with leadership bringing us closer to an Integrated Care Model
next steps
Next Steps
  • Formally establish health education groups in addition to 1:1 delivery of patient education
  • Establish a physical health group (2nd Y-Group started 2/12)
  • Increase FNP time at the ACT team office site to enable care for both Waterville as well as the Augusta Case Load
  • Continue to work on the Integrated Care Model as many clients see this as their medical home
  • Bodenheimer, T., Wagner, E. H., & Grumbach, K. (2002). Improving primary care for patients with chronic illness. JAMA, 1775-1779.
  • Coleman, K., Austin, B. T., Brach, C., & Wagner, E. H. (2009). Evidence on the chronic care model in the new millennium. Health Affairs, 28(1), 75-85.
  • Colton, C. W., & Mandersheid, R. W. (2006, April 05). Congruencies in increased mortality rates, years of potential life lost, and causes of death among public mental health clients in eight states. Retrieved from 0180.htm
  • Dutta, T. (2010, October 21). Retrieved November 15, 2011, from SAMHSA:
  • Freeman, E. (2009). The Poor Health Status of Consumers of Mental Health Care the Interaction of Behavioral Disorders and Chronic Disease. Department of Health and Human Services. Augusta.
  • Freeman, E., Presley-Cantrell, L., Edwards, V. J., White-Cooper, S., Thompson, K. S., Sturgis, S., & Croft, J. (2010). Gathering partnerships to bridge gaps among mental health, health care and public health. Preventing Chronic Disease, 1-7. Retrieved Nov 05, 2011, from
  • Institute of Medicine, Committee on Quality of Health Care in America. (2001). Crossing the quality chasm: a new health system for the 21st century (executive summary).
  • Murphy, J. (2011). Patient as center of the health care universe: a closer look at patient-centered care. Nursing Economic$, 35-37.
  • Wagner, E. H., Austin, B. T., Davis, C., Hindmarsh, M., Schaefer, J., & Bonomi, A. (2001). Improving chronic care: translating evidence into action. Health Affairs, 64-78.
  • Weinstein, L. C., Henwood, B. F., Cody, J. W., Jordan, M., & Lelar, R. (2011). Transforming assertive community treatment into an integrated care system: the role of nursing and the primary care partnerships. Journal of the American Psychiatric Nurses Association, 64-71.