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Impact of Visit Length on Operational & Financial Outcomes in Pediatric Integrated Primary Care
Tawnya Meadows, PhD, BCBA-D, Co-Chief of Behavioral Health in Primary Care, Geisinger, Danville, PA
Sean O'Dell, PhD, Associate/Clinical Investigator, Geisinger, Danville, PA
Shelley Hosterman, PhD, Co-Chief of Behavioral Health in Primary Care, Geisinger, Danville, PA
Session # I6
CFHA 20th Annual Conference
October 18-20, 2018 • Rochester, New York
Faculty Disclosure
The presenters of this session have NOT had any relevant
financial relationships during the past 12 months.
Conference Resources
Slides and handouts shared in advance by our Conference Presenters are available on the CFHA
website at http://www.cfha.net/?page=Resources_2018
Slides and handouts are also available on the mobile app.
Learning Objectives
At the conclusion of this session, the participant will be able to:
• List steps involved in changing template from a 60-minute to 30-minute model
• Describe impact on access outcomes related to changing length of patient slots
• Discuss implications of changing length of patient slots on outcomes related to financial sustainability
1. Asarnow, JR, Rozenman, M., Zeltzer, L. (2015). Integrated Medical-Behavioral Care Compared with Usual Primary Care for
Child and Adolescent Behavioral Health: A Meta-Analysis. JAMA Pediatrics; 169(10); 929-937
2. Rhoward, KI, Kopta, SM, Krause, MS, & Orlinsky, DE (1986). The dose-effect relationship in psychotherapy. American
Psychologist, 41(2), 159.
3. Turner, PR, Valtierra, M, Talken, TR, Miller, VI, & DeAnda, JR (1996). Effect of session length on treatment outcome for
college students in brief therapy. Journal of Counseling Psychology, 43(2), 228
4. Corso, KA, Bryan, CJ, Corso, ML, Kanzler, KE, Houghton, DC, Ray-Sannerud, B, & Morrow, CE (2012). Therapeutic alliance
and treatment outcome in the primary care behavioral health model. Famlilies, Systems, & Health, 30(2), 87.
5. Reiter, JT, Dobmeye, AC, Hunter, CL (2017). The primary care behavioral health (PCBH) model: An overview and operational
definition. Journal of clinical psychology in the medical setting, 1-18.
6. O’Brien, D., Harvey, K., Howse, J., Reardon, T., & Creswell, C. (2016). Barriers to managing child and adolescent mental
health problems: A systematic review of primary care practitioners’ perceptions. British Journal of General Practice, 66,
e693-e707. doi:10.3399/bjgp16X687061
7. Njoroge, W. F. M., Hostutler, C. A., Schwartz, B. S., & Mautone, J. A. (2016). Integrated behavioral health in pediatric primary
care. Current Psychiatry Reports, 18. doi:10.1007/s11920-016-0745-7
8. Torio, C. M., Encinosa, W., Berdahl, T., McCormick, M. C., & Simpson, L. A. (2015). Annual report on health care for children
and youth in the United States: National estimates of cost, utilization, and expenditures for children with mental health
conditions. Academic Pediatrics, 15, 19-35. doi:10.1016/j.acap.2014.07.007
9. Turner, P. R., Valtierra, M., Talken, T. R., Miller, V. I., & DeAnda, J. R. (1996). Effect of session length on treatment outcome for
college students in brief therapy. Journal of Counseling Psychology, 43, 228-232. doi:10.1037/0022-0167.43.2.228
10. Valleley, R. J., Kosse, S., Schemm, A., Foster, N., Polaha, J., & Evans, J. H. (2007). Integrate primary care for children in rural
communities: An examination of patient attendance at collaborative behavioral health services. Family, Systems, & Health,
25, 323-332. doi:10.1037/1091-7527.25.3.323
11. Vogel, M. E., Kanzler, K. E., Aikens, J. E., & Goodie, J. L. (2017). Integration of behaviora health and primary care: Current
knowledge and future directions. Journal of Behavioral Medicine, 40, 69-84. doi:10.1007/s10865-016-9798-7
Bibliography / Reference
Learning Assessment
A learning assessment is required for CE credit.
A question and answer period will be conducted at
the end of this presentation.
8
Impact of Visit Length on Operational &
Financial Outcomes in Pediatric
Integrated Primary Care
9
Background & Need
10
2018-2019
Pottsville
Bloomsburg
Selinsgrove
Orwigsburg
Susquehanna Sunbury
Extension - ON
Hub
Woodbine
Mt Pleasant
Lock Haven
Pittston
Mt Pocono
Forty Fort
Lewistown
Shamokin
Grey’s Woods
Nanticoke
Extension - OFF
11
12
13
Pediatric Integrated Care Model
• Rural setting
• Hybrid model
• Limited referral options
• Most treated in house
Primary mission: Access
14
Pilot Clinics 2011
Pottsville
BloomsburgSelinsgrove
Orwigsburg
Extension
Hub
15
Pilot Template Structure
Monday Tuesday Wednesday
9:00-10:00 Patient Slot Patient Slot Patient Slot
10:00-11:00 Patient Slot Patient Slot Patient Slot
11:00-12:00 Patient Slot Patient Slot Patient Slot
12:00-1:00 LUNCH/Meetings LUNCH/Meetings LUNCH/Meetings
1:00-2:00 SUPERVISION Leigh Consultation/WHO/Paperwork SUPERVISION Leigh
2:00-3:00 Patient Slot Patient Slot Patient Slot
3:00-4:00 Patient Slot Patient Slot Patient Slot
4:00-5:00 Patient Slot Patient Slot Patient Slot
5:00-6:00 Patient Slot DBC Group ACT Group
6:00-7:00 DBC Group ACT Group
16
Problems
with Pilot
Model
17
Program
Consultation
Dr. Manson
18
Revised Template Structure
19
Timeline for Change
Spring 2017
Summary consult/recs
Team discussion*
Sample templates
Provider choice/benefit
Summer 2017
Team leads piloted
Kept notes & observations
Shared tips/tricks with team
Developed supporting materials
Fall 2017
Rolled out in additional clinics
Data dashboard development
2017-2018
Continued model
New system metrics
Monthly check-ins
Select clinics back to 60
20
Material
Preparation
Orienting key stakeholders
• Patients*
• PCPs*
• Office staff*
Clinician support
• More clocks
• Laminated problem sheets
• Treatment plan format*
(later)
• Planning sheet*
21
Clinician Support - Sample Agenda
Minutes Tasks
5 minutes
Review patient planning form (if using)
Discuss home practice task
Update symptom rating
Problem solve (as needed)
20 minutes
Agree on today’s topic/skill
Introduce & practice new skill
5 minutes
Agree on home practice plan details
Set data collection plan
22
Clinician Support – Tx
Plan & Documentation
23
Tx Plan &
Documentation
24
Evaluation & Impact
25
Evaluation Plan
• Comparison Site
• Staffing: 2 full time psychologists, 4 FTE interns
• Referral sources: anyone within 5 county area
• IPC Sites
• Staffing: 2.5 Clinic leads/psychologists, .4 FTE Interns, 2 FTE
Postdocs
• Referral sources: On site PCPs or collaborating partner
|
26
FinancialWhat administrators see….B
elo
w B
udget
Above B
udget
27
What administrators see….
We will
never make
budget.
What do the
clinicians do
all day?
This 30 minute
template is a
bad idea.
Be
low
Budget
Above B
udget
We are
losing
money
Financial
I am going
to lose my
job.
28
What clinicians feel….B
elo
w B
udget
Abo
ve B
ud
ge
t
IPC 30 Minute Template: Billable Hours Per FTE
January through March 2017 (Blue) and 2018 (Red)
Jan Feb Mar
Clinical
29
What clinicians feel….B
elo
w B
udget
Abo
ve B
ud
ge
t
IPC 30 Minute Template: Billable Hours Per FTE
January through March 2017 and 2018
I am working
so much
This 30
minute model
is awesome!
I am serving
so many more
families ☺
I’m in the
money…
Jan Feb Mar
I just
bought a
house…
I left work
on time
30
What Shelley/Tawnya see….Operational
31
What Shelley/Tawnya see….
Maternity Leave,
Staff turnover …Summer
drop off
Interviews
32
What Shelley/Tawnya see….60 Minute template= Average 77.7 Billable Hours/FTE per Month
30 Minute template= Average 105.8 Billable Hours/FTE per Month
Goal= 96
33
OperationalSlot Utilization
0
20
40
60
80
100
120
140
160
60 min IPC 30 min IPC
0
20
40
60
80
100
120
140
160
Specialty Year 1 Specialty Year 2
34
OperationalFill rate
0
20
40
60
80
100
120
140
IPC 60 min IPC 30 min
0
20
40
60
80
100
120
140
Specialty Year 1 Specialty Year 2
35Operational
Percent of New Patients Seen 10 days or Less
0
10
20
30
40
50
60
70
80
90
100
60 min IPC 30 min IPC
0
10
20
30
40
50
60
70
80
90
100
Specialty Year 1 Specialty Year 2
36
What Researchers Feel…
37
What Researchers Actually Feel…
Biglan et al., 2012;
Merikingas et al., 2010;
Olfson et al., 2014
Bodenheimer et al., 2014;
Croghan & Brown, 2010;
Peek et al., 2014
38
What Researchers See….
Effort
Impact
✓ Innovation
✓ Real System
Improvement
✓ Data-Based Decision
Making and
Accountability
39
Evaluation & Impact: Billable Hours per FTE
Parameter Estimate (SE) 95% CI P-Value
Pre-Level 85.39 (11.57) 61.26, 109.51 ---
Post-Level Change 17.29 (17.24) -18.68, 53.25 0.328
Pre-Trend 0.012 (1.34) -2.78, 2.80 0.993
Post-Trend Change 2.25 (2.68) -3.33, 7.83 0.409
Post-Trend 2.27 (2.32) -2.57, 7.10 0.340
Hypothesis: Level
Change for the Better
Supported by the data?:
No; however, trend looks
promising
40
Evaluation & Impact: Slot Utilization
Parameter Estimate (SE) 95% CI P-Value
Pre-Level 89.20 (8.23) 72.04, 107.37 ---
Post-Level Change -43.88 (9.71) -64.13, -23.62 <0.001
Pre-Trend 3.44 (1.08) 1.18, 5.71 0.005
Post-Trend Change -0.22 (1.91) -4.20, 3.76 0.911
Post-Trend 3.23 (1.57) -0.05, 6.50 0.053
Hypothesis: Anticipate
initial deterioration, but
over time no change
Supported by the data?:
Partially; initial
deterioration observed,
but not full recovery
41
Evaluation & Impact: % Seen Within 10 Days
Parameter Estimate (SE) 95% CI P-Value
Pre-Level 72.63 (3.21) 65.76 – 79.51 --
Post-Level Change 12.05 (9.93) -9.25, 33.34 0.245
Pre-Trend -1.90 (0.68) -3.36, -0.44 0.014
Post-Trend Change 0.37 (1.66) -3.19, 3.94 0.826
Post-Trend -1.53 (1.52) -4.78, 1.72 0.330
Hypothesis: Level
Change for the Better
Supported by the data?:
No
42
Evaluation & Impact: Fill Rate
Parameter Estimate (SE) 95% CI P-Value
Pre-Level 91.28 (6.60) 77.51, 105.05 ---
Post-Level Change -44.47 (15.94) -77.71, -11.23 0.011
Pre-Trend 2.75 (1.65) -0.69, 6.19 0.111
Post-Trend Change -1.71 (2.02) -5.92, 2.51 0.409
Post-Trend 1.04 (1.17) -1.40, 3.49 0.3823
Hypothesis: No Change
Supported by the data?:
No; deterioration
immediately apparent
43
Other Considerations
Satisfaction
-Patient
-BHC
-PCP
-PAR
WHO and Collaboration frequency
Group sustainability
44
Lessons Learned & Next Steps
45
Research Lessons/Tips
46
Clinical Lessons/Tips
Benefits
More time!
After school visits
Less overriding
Work/life balance
Clinical partners pleased
Increase efficiency
Integrity in agenda/tx plan
Referring complex pts
Challenges
Transitioning patients
Complex sessions
•Exposures
•Family conflict
•Trauma
•Crisis
WHO's during session
Late patients
"Oh by the way....."
47
Clinical Lessons/Tips
48
Questions & comments welcome!!
49
Contact information
Tawnya Meadows [email protected]
Sean O’Dell [email protected]
Shelley Hosterman [email protected]
Session Evaluation
Use the CFHA mobile app to complete the evaluation
for this session.
Thank you!