Integrated Primary Care Practice in a Federally Qualified Health Center:

Moving ForwardAndrea Auxier, Ph.D.

Director of Integrated Services and Clinical TrainingKatrin Seifert, Psy.D.

Associate Psychology Training Director

Salud Family Health Centers, Colorado

Collaborative Family Healthcare Association 13th Annual ConferenceOctober 27-29, 2011 Philadelphia, Pennsylvania U.S.A.

Session # Track H4aOctober 29, 201110:30 AM

Faculty Disclosure

We have not had any relevant financial relationships during the past 12 months.

Need/Practice Gap & Supporting Resources

In a progressively complex and fragmented healthcare system and in response to the need to provide whole-person, quality care to greater numbers of patients than ever before, primary care practices throughout the country have turned their attention and efforts to integrating behavioral health into their standard service-delivery models. With few resources and little guidance, systems struggle to gather the support required to establish effective integrated programs. Based on first-hand experience, we describe the development of a working integrated primary care model being utilized in in a large community health center system in Colorado.

Objectives

1. Identify practice-specific and system-specific factors to consider when setting up an integrated practice

2. Describe how practice-based research can inform service-delivery and organizational protocols

3. Describe how a focus on training can be leveraged both financially and clinically

4. Identify a population-based model of integrated care being utilized in a large FQHC system

Expected Outcome

The purpose of the talk is to provide participants with a broad range of considerations to utilize when establishing integrated

practices.

The cost of doing something that may work is less than the cost of continuing to do something that definitely won’t.

In 2008, mental health conditions accounted for $72 billion in expenditures, making them the third most costly condition (along with cancer), exceeded only by heart conditions and trauma-related disorders. (AHRQ 2008)

75% percent of total health care spending in 2007 went towards the treatment of chronic diseases, such as diabetes and asthma. (CMS)

Healthcare costs are rising 6% a year. (Source: Congressional Budget Office)

Why are we in such a pickle?

Divided systems breed divided practice

Payment

• Carved out systems

• Fee for service vs. capitation

• We’ll pay you to do it there, but not there

Recommendations1) Create New Departments

Behavioral healthData managementEHR designPolicies, Procedures, and Training

2) Put people in charge of them3) Talk to each other!4) Balance executive decisions with democratic processes5) Dispense with the silos

• Diffusion of responsibility• Duplication of efforts• Inefficient processes• Unspoken expectations become breeding

grounds for resentment

Dispensing with the Silos

A necessary integration of previously divided sections of the organization

Medical

Behavioral

Dental

Education

Human Resources

Information Technology

Accounting & Finance

Facilities Management

Reporting

Client Services

Administrative Services Development

The Old Way

The New WayCare Coordination

Referral Tracking

Proactive Management of Targeted Patients

(e.g., asthma, depression, COPD, narcotics)

Self Management Goals

Collaborative Treatment Planning

Visit Summaries

THE SALUD STORYIdea to Implementation

FORT LUPTON 1970 FREDERICK 1978 MOBILE UNIT 1979

BRIGHTON 1980

LONGMONT 1979

COMMERCE CITY 1986

STERLING 2001

FT. COLLINS 2002

FT. MORGAN 1994

ESTES PARK 1992

What is an FQHC?

MUA/MUP

Revenue Mix20%

20%60%

Federal Grant

Non-Federal Grants

Pt Services

Payer Sources 7%7%

30%56%

Medicare

Private Insurance

MedicaidUninsured

Challenges

• Many patients, not so much money• Turf issues• Common goals vs. competing objecting

objectives– Internally– Externally

Team Composition19 FTE Behavioral Health - 7 Psychology Postdoctoral Fellows

Collaboration

• Put it in writing!• Make expectations explicit.• Define reporting relationships

Collaboration Requirements• Are, at minimum, master’s level clinicians licensed in the state of CO• Are at least half time (.5FTE) • Adhere to Salud’s integrated care model • Do not discriminate by payer source or patient’s county of residence• Are part of the behavioral health department; attend departmental meetings • Are credentialed through Salud human resources prior to start date• Document patient encounters in Salud EMR only• Bill for patient encounters utilizing Salud Standard Operating Procedures for

behavioral health billing. Certain types of co-payments and third-party reimbursements can be collected by partner agency if agreed to and documented in a Memorandum of Understanding signed by both parties.

• Report to the Director of Integrated Services & Clinical Training• Are subject to formal evaluation processes

Estes Park.5FTE

Ft. Collins5 FTE

2 PT psychiatrists

Longmont2 FTE

1 PT psychiatrist

Ft. Morgan1 PT psychiatrist

Sterling

Frederick1 FTE Ft. Lupton

2 FTE1 Case Manager

Brighton2 FTE

Commerce City2 FTE

Non-Clinical Positions

Director of Integrated Services 1FTE

Associate Psychology Training Director 1FTE

North RangeBH

Centennial

Larimer Center

Health District

Mental Health Partners

Early Considerations

• Who are the patients?• What do they need?• What resources are there in the community?• When will we refer, and for what reasons?• Will the patients go?• Will they get in?• What will we do if they come back?

Service-Delivery

PCP Initiated

Consultation, Evaluation, & Brief Interventions

Patient Initiated

Therapy

BHP Initiated

Screening

A completely integrated primary care system that provides quality population-based care through

improved access

Adult Screening to Treatment Protocol

Referral to MHC/ Specialty Service

Referral to MHC/ Specialty Service

What we Know

• Depression: 35% • Anxiety: 35%• Trauma: 13%• Alcohol: 10%• Substances: 4%• Smoking: 30%• Safety of Living Environment: 2%

What it Means

It’s not just about depression

Disease-specific models are for people with specific diseases treated in systems that can accommodate disease-specific models

How we Pay for ItPatient Revenue

Copayments for therapy and testing

Leveraging the power of the mission statement

Comparative Effectiveness ResearchScalable Architecture for Federated Translational Inquiries Network

Workforce Development

Imagining a world without BHPs

Looking down the RoadMedical Home & ACOs

Workarounds or Solutions?

Successes• Staffing on a shoestring budget• A standardized service-delivery model• Behavioral health woven into the organizational fabric• Clinical Training Program• Relationships with outside agencies moving in

positive directions• 14,000 patients served/yr• Integration of comparative effectiveness research

efforts

Lessons Learned

Do what we can to do today to help us build the case for doing it tomorrow

Foster relationships – at ALL levels

Always look down the road (PCMH, ACO)

Be patient: Transformational change takes time

Remember What it’s Really About

Meaningful use of meaningful measures

Embrace the good enough principle

Do vs. think about doing whenever possible

Process informs evolution

Strategies trump models

Build the infrastructure to support the idea

September 2010 Goals

• Increase size of BH team• Expand training program• Increase health psychology services• Expand service delivery (child, addiction)• Research

Directions

• Promote clinically meaningful and organizationally feasible research

• Hire people to do what they’re trained (and love) to do

• Emphasize continuous quality improvement• Never stop growing!

Learning Assessment1) According to the Congressional Budget Office, healthcare costs in the Unites States are rising at a rate of what percent per year?:

a) 3% b) 6% c) 9% d) 12%

2) What percentage of an FQHC’s board must be comprised of patients?

a) 0% b) 10% c) 50% d) more than 50%

3) Which of the following is NOT a standardized screening tool

a) PHQ-9 b) PCL c) PDI d) DAST

Session Evaluation

Please complete and return theevaluation form to the classroom monitor

before leaving this session.

Thank you!