integrated primary care, behavioral health care …program objectives • to identify and provide...

INTEGRATED PRIMARY CARE,

BEHAVIORAL HEALTH CARE

AND WELLNESS

Dona Rivera Gulko, MS, CRC, CCM, CODAC

Laurie Robinson, MTS, El Rio Community

Health Center

Barbara Estrada, MS, Impact Consultants, Inc.

Whole Health Program

Funded by Substance Abuse Mental Health Services

Administration/Center for Mental Health Services (SAMHSA/CMHS)

Grant SM-09-011

Purpose

• Collaborative effort by CODAC and El Rio

Community Health Center (El Rio) to

establish an integrated system of care

• Improve the physical health status of 1,000

adults with serious mental illness at CODAC

• Deliver fully integrated mental health,

primary medical and wellness services,

established a Patient Centered Health Care

Home

Need • “people living with serious mental

illnesses are dying 25 years earlier than the rest of the population, in large part due to unmanaged physical health conditions.” (National Council for Community Behavioral Healthcare, April, 2009)

• They are dying at twice the rate of and approximately 25 years earlier than the general population (Parks, J., et al, October 2006), due to often highly preventable illnesses

16 State Study Results: Years of Potential Life Lost

Year AZ MO OK RI TX UT VA

(IP only)

1997 26.3 25.1 28.5

1998 27.3 25.1 28.8 29.3 15.5

1999 32.2 26.8 26.3 29.3 26.9 14.0

2000 31.8 27.9 24.9 13.5

Need

• Over 1.8 million people in the U.S. – 1 one of every 17 people – have a serious mental illness such as schizophrenia, bipolar disorder, or major clinical depression (National Institute for Mental Health Statistics, 2008)

• Persons with serious mental illness are subjected to a serious health disparity

SAMHSA RFP Issued

• Over 300 applicants applied for funding

• CODAC Behavioral Health Services one

of thirteen orginal grantees awarded

funding of $500,000 annually for four

years beginning October 1, 2009

Program Objectives • To identify and provide wellness, preventive and primary

health care to persons with serious mental illness who also have diabetes to: – Reduce the percentage of persons with poor HbAlc control to

15% or less

– Refer and screen at least 80% of persons annually for completion of a retinal exam

– Complete foot evaluations on 95% of persons at each visit.

• To identify and provide wellness, preventive and primary health care to persons with serious mental illness to improve management of symptoms/contributing factors of cardiovascular disease/heart disease by: – Performing blood pressure readings at each visit

– Conducting fasting lipid profiles annually

Program Objectives

• To reduce disease, disability and death from cancer through wellness education, prevention, screening (breast, cervical and colon cancer as age and gender appropriate) and treatment – Women older than 41 to have had a mammogram in the

past 2 years with goal of >70%

– Women older than 20 who have had a Pap smear in the last 3 years with goal of >90%

– More than 50% of adults older than 50 to be screened with at least one of the following: • FOBT within one year

• Sigmoidoscopy within 5 years

• Colonoscopy within 10 years

Program Objectives • To reduce disease, disability and death from

infectious diseases; including vaccine-preventable diseases – Adult served age 65 and older to be vaccinated for

influenza with a goal of 90%

– Adults served age 65 and older to be vaccinated with pneumococcal vaccine with a goal of 90%

– Adults aged 18 to 64 years to be vaccinated for influenza with goal of 60%

– Adults age 18 to y4 years to be vaccinated with pneumococcal vaccine with goal of 60%

– Provide HIV screenings for all adults identified as at-risk

– Provide HIV/AIDS education, counseling and primary health care for adults who are identified

HIV/AIDS positive.

Program Objectives • To identify and provide wellness, preventive and

primary health care and effectively treat tobacco

use and dependence

– Assessment and education to help adults stop tobacco

use

– Tobacco Cessation to include:

• self-help exercises

• stress-management

• promote problem solving skills, goal setting and

decision making

• encourage relapsed smoker to try again

• prescription of nicotine

replacement therapy

Evidence-Based Practices (EBP)

• Screening, Brief Intervention and

Referral to Treatment (SBIRT)

• Dialectical Behavior Therapy (DBT)

• Seeking Safety Treatment

• Person-Centered Healthcare Home

(PCHH) model

Staffing Pattern • FNP or MD can serve 1,000 persons annually with the

assistance of:

– Registered/Licensed Practical Nurse

– Medical Assistant

– Medical Office Specialist

• Three Exam Rooms per FNP/MD are optimal

• Care Coordinators (3) ensure excellent coordination of care

• Wellness/Peer Specialists (3) ensure good outcomes

First Year Costs

• Building Modifications $ 32,000

• Desktop Computers $ 13,500

• Software Licenses $ 5,000

• Telephones $ 1,000

• Exam Room Equipment (3) $ 6,000

• Office Furnishings $ 4,800

• Medical Supplies $ 5,000

• Office Supplies $ 3,000

• Staffing $485,000

• TOTAL $555,300 plus admin costs

Annual Sustainability Costs

• Medical Supplies $ 5,000

• Office Supplies $ 3,000

• Staffing $485,000

• TOTAL $493,000 plus admin costs

Lessons Learned • Cultures of collaborating agencies are

integral to the success of providing integrated care. A new “Whole Health Culture” had to be built.

• Whole Health staff must become part of CODAC processes and protocols.

• Conflicting organizational policies needed to be discovered, discussed and revised.

Lessons Learned • Being in the same building is not

integrated care. Staff from all programs must be intertwined and work collaboratively.

• The importance of development and ongoing revision of an efficient work flow.

• Use of an Electronic Health Record that supports integrated health care is essential.

Barriers and Solutions • Plan to build bridge between two

different EHR systems was too time intensive and too expensive. Solution?

• Delay in state licensure of medical services. Solution?

• Medication seeking members. Solution?

• Lower levels of program enrollment than anticipated. Solution?

Contact Information

Dona Rivera-Gulko

Vice-President for Adult Services

CODAC Behavioral Health Services

drivera@codac.org

WELLNESS

?

WELLNESS

Whole Health Population Context

– SMI

– Stigma

– Trauma

– Periodic Homelessness

– Poverty

Definitions & Components Wellness

• Culturally Relevant

• Health Literate

• Trauma Informed

• Integrated-MH/PH

• Natural-Unintentional Bias

• Community Linked

• Sustainable

• ACE Study- www.cdc.gov/ace/index.htm

• Smoking Cessation Research on SMI

• Wellness Inventory and Coaching Models

• Psychosocial Rehab Approach

• Community Resource Mapping

Program Development Resources

Wellness Program Development

• Comprehensive Understanding of Wellness- Mind, Body, Spirit, Community

– Modified 7 Domain Wellness Assessment Tool-Wellness and Recovery Institute ,CSP NJ

• Overall Physical Health

• Nutrition

• Physical Activity

• Sleep/Rest

• Relaxation/Stress Management

Program Development

• Added Two Additional Domains

– Relationships

– Meaningful Activity

Wellness Program Development

• 3 CODAC Wellness Specialists-

– PH and PE Backgrounds

– 2 Trained w/CSP as Wellness Coaches

Our Sedentary Lifestyles are Killing Us

• THIS MEANS YOU

Wellness Program Development

• Physical Activity- Individualized and Community Based

– Partnership with FitCenter (MidValley Athletic Association)

– Yoga , Wii and Zumba at CODAC site

– Summer Sports-Badminton

– Dog Walking/Cat Petting

On the courts, rackets in hand

Wellness Program Development

• Healthy Eating

– Diabetes Educator- El Rio CHC

– Healthy Cooking Demos at Residences

– Individual Sessions

– Joyful Eating Group

Wellness Program Development

• Smoking Cessation-

– Wellness Specialist Trained, U of A Prevention Program –one on one sessions

– AZ ASHline

• CPPW Grant Specialized SMI Resources

• ASHline Training of Whole Health Staff

• El Rio Referrals EMR

Community Based

• Community Resources

– CPPW Grant- Communities Putting Prevention to Work Grant, Pima Co

•Healthy Vending Machines-Policy and Procedures

•Walking Groups & Ed Sessions

Community Resources

El Rio Health Education Project

– Health Promotion Training Modules

Volunteering at Community Food Bank and Farm

Engagement and Enjoyment Trips-DeGrazia Gallery

Development of Peer Orientation Volunteers at MidValley Athletic Association

Sorting at the food bank

THE WHOLE HEALTH ADVISORY BOARD

Roger K., Allison L., Linda C, Letitia R., David R.,

Eric H., KC J., Jerry S.

Peer Leadership

• Whole Health Advisory Board

– Bulletin Board

– Healthy Vending Machines

– Lobby Demos

• Peer Fitness Center Orientation Volunteer

– In Development

There's a direct relationship between

attending museums and wellness.

Enrollment and Retention

• From January 1, 2010-March 31, 2012: – 755 Members enrolled

– 401 Members assessed at 6 months

– 269 Members assessed at 12 months

– 123 Members assessed at 18 months

– 71 Members assessed at 24 months

– 193 Members discharged

– Disconnected is the main reasons for drop out (61%)

Demographics (n=745) Characteristic n %

Male 331 44.3

Female 416 55.6

Hispanic 141 18.9

White 588 78.6

Black 57 7.6

American Indian 44 5.9

Native Hawaiian 18 2.4

Asian 8 1.1

Alaska Native 5 0.7

Characteristic n %

18-24 50 6.7

25-34 165 22.1

35-44 182 24.3

45-54 215 28.7

55-64 117 15.6

65-74 14 1.9

75-84 5 0.7

Housed (own or other’s) 625 83.5

Other 116 16.5

HS or less 348 41.1

Vocational, College, etc. 391 52.4

Service Utilization

• 3623 visits for physical health screening/ assessment

• 45,065 visits for mental health screening/ assessment

• 24,966 visits included comprehensive case management

• 24,087 visits included integrated dual diagnosis treatment

• 18,264 visits for SBIRT and MET (each)

• 45,065 visits for substance abuse screening/ assessment

• 3623 visits included wellness programming

Wellness Assessments

• 372 Member visits

• Members rated 9 aspects of their wellness using a 7 point Likert scale (1=Very Dissatisfied to 7=Very Satisfied)

Wellness Domain Satisfaction

Physical Activity 3.26

Overall Physical Health 3.67

Nutrition 3.86

Relaxation/Stress Management 3.73

Sleep/Rest 4.09

Meaningful Activity 4.28

Relationships 4.41

Medical Care/Screening 5.30

Environment 4.82

Wellness Assessments (Fitness)

• A total of XX Members attended the Fit Center (XXX visits). On average, Members attended X.XX times.

• 78 Members fitness screened during visits.

• Seven fitness tests completed with Members

• Rated as either below average, average, or above average (1, 2, and 3 respectively) in each area.

Chair

Stand

Arm

Curl

6 min walk

/2 min Step

Chair Sit

and Reach

Back

Scratch

Up and

Go

Balance

Below

Average 32 22 28 12 20 0 12

Average 17 31 21 28 16 1 16

Above

Average 4 5 9 9 8 2 28

Average

Score 1.18 1.50 1.48 1.44 1.33 0.73 2.29

Functioning (Past 30 Days) Characteristic n %

Overall Health

Excellent 19 3.5

Very Good 46 8.5

Good 145 26.7

Fair 206 37.9

Poor 128 23.5

Characteristic SD D N A SA

Deal with daily problems

5.4 31.4 10.0 48.0 5.1

Control my life 5.3 29.1 14.7 46.0 4.9

Deal with crisis 6.7 32.1 18.1 39.3 3.8

Get along with family 6.0 18.3 9.6 53.1 13.0

Do well in social situations

7.8 30.8 10.3 44.8 6.3

School/Work 5.6 28.8 15.8 39.8 10.0

Housing is satisfactory 7.2 18.6 4.6 56.1 13.5

Symptoms not bothering me

17.4 53.8 5.5 21.3 1.9

Functioning (Past 30 Days)

Characteristic n %

How often did you feel*:

Nervous 308 56.3

Hopeless 175 32.0

Restless 269 49.2

Depressed 124 22.9

Everything was an effort 243 44.5

Worthless 160 29.3

Characteristic n %

How often have you used**:

Tobacco 322 58.9

Alcohol 67 12.2

Cannabis 67 12.2

Cocaine, Stimulants, Meth, Inhalants, Hallucinogens, Sedatives and Opioids each < 2%

*All or most of the time **Weekly or more frequently

Stability in Housing, School/Work (Past 30 Days)

Characteristic n %

Zero Nights Spent:

Homeless 506 92.3

Hospital for MH 475 86.7

Detox 537 98.0

Jail 532 97.1

Zero Times Spent

Times gone to ER for MH 480 87.6

Characteristic n %

Currently not:

Enrolled in school/Training

680 91.6

Employed (=Disabled) 317 42.8

Zero times arrested 718 96.0

Housing not disrupted, but not working or in school

Social Connectedness (Past 30 Days)

Characteristic SD D N A SA

Happy with the friendships I have 3.1 19.8 7.7 62.1 7.3

I have people with whom I can do enjoyable things

2.4 18.6 5.7 65.0 8.3

I feel like I belong in my community 3.5 25.8 11.9 55.3 3.4

In a crisis, I would have the support I need from family or friends

3.0 14.4 8.0 64.3 10.3

MEMBER CHARACTERISTICS OVER TIME

Changes in Health Outcomes Health Indicator 01/2011 12/2011

Blood Pressure (systolic)

<120

120-139

140-159

160+

Blood Pressure (Diastolic)

<80

80-89

90-99

100+

Health Indicator 01/2011 12/2011

BMI

<18.5

18.5-24.99

25.00-34.99

35.00-39.99

40+

Fasting Plasma

Glucose

<99

100-125

126+

Changes in Health Outcomes

Health Indicator 01/2011 12/2011

HgbA1c

<5.7

5.7-6.4

6.5+

Total Cholesterol

<200

200+

HDL

<40

41-59

60+

Health Indicator 01/2011 12/2011

LDL

<100

100-129

130-159

160-189

190+

Triglycerides

<150

150-199

200-499

500+

1

2

3

4

5

Baseline 6 Mo 12 Mo 18 Mo 24 Mo

Functioning

OverallHealth

HandlingDailyLife

ControlLife

DealWithCrisis

GetsAlongWithFamily

SocialSituations

SchoolOrWork

FunctioningHousing

Symptoms 1: Strongly Disagree 5: Strongly Agree

0

1

2

3

4

Baseline 6 Mo 12 Mo 18 Mo 24 Mo

Depression

Nervous

Hopeless

Restless

Depressed

EverythingEffort

Worthless

0: None of the time 5: All of the time

1: Never 4: Daily or almost daily

1

2

3

4

Baseline 6 Mo 12 Mo 18 Mo 24 Mo

Substance Use

Tobacco_Use

Alcohol_Use

Cocaine_Use

0

1

1

2

2

Baseline 6 Mo 12 Mo 18 Mo 24 Mo

Housing Stability Past 30 Days

NightsHomeless

NightsHospitalMHC

NightsDetox

NightsJail

TimesER

NumTimesArrested

1

2

3

4

5

Baseline 6 Mo 12 Mo 18 Mo 24 Mo

Perception of Care

Recover

Complain

Rights

Responsibility

SideEffects

SharingTreatmentInformation

SensitiveToCulture

InformationNeeded

ConsumerRunPrograms

ComfortableAskingQuestions

TreatmentGoals

LikeServices

Choices

RecommendAgency

1:Strongly Disagree… 5: Strongly Agree

1

2

3

4

5

Baseline 6 Mo 12 Mo 18 Mo 24 Mo

Social Connectedness

Friendships

EnjoyPeople

BelongInCommunity

SupportFromFamily

1: Strongly Disagree… 5: Strongly Agree

WHOLE HEALTH DATA COLLECTION: IMPLEMENTATION ISSUES

Changes Impacting Data Collection

• Quarterly report format changes

• Clinical Registry changes

• Cross-site Evaluator late start

• EHR data sharing

• Changes to the Client Level Tool (new NOMs requirements for adult programs)

• Staffing changes