The Integration Toolkit: A Population Based Shift to Behavioral Primary Care

TransformationConnie van Eeghen, Dr.PH, MHSA, MBA

Assistant Professor

General Internal Medicine,

Rodger Kessler Ph.D. ABPP

Associate Professor

Family Medicine

The University of Vermont

College of Medicine

Collaborative Family Healthcare Association 17th Annual ConferenceOctober 15-17, 2015 Portland, Oregon U.S.A.

Session # D4bSaturday, October 17, 2015

Faculty Disclosure

The presenters of this session…

• have NOT had any relevant financial relationships during the past 12 months.

Learning Objectives

At the conclusion of this session, the participant will be able to:

• List the core elements of the Integration Toolkit

• Identify the necessary steps to implement the Toolkit

• Discuss an application in a real world practice

Learning Assessment

• A learning assessment is required for CE credit. Please fill out the evaluation at the end of the presentation.

• A question and answer period will be conducted at the end of this presentation.

Background

Primary care transformation: process improvement and defined work flows to change care deliveryHow: established improvement technologies from the manufacturing world and adapted within heath careApplication to Behavioral Care within Primary Care: find a clinician, place into office, and make referralsMissing: attention to process improvement and work flowsAlternative Application: NIH supported integration toolkit, based on Lean methodology, adapted to primary care settings

Assumptions underlying toolkit

•Our focus: behavioral care is provided within the primary care office •DOES NOT: “improve external referrals” •DOES move practices from Co-location to Integration•Co-location and Integration are more different than the same

The 30,000 foot view: Toolkit Dimensions

•Executive decision making – pre-requisite•Practice leadership and facilitation•Process design and redesign • Implementation•Measurement•Outcomes• Integration process (PIP)

Integration Orientation

•Referral model•Data-driven model•More different than the same

Every system is perfectly designed to generate exactly the outcomes it gets (Hanna, 1988)

Toolkit Orientation

• One universal goal; variable solutions (Bate 2008)

• Lean: a structured problem-solving approach • Multi-functional teams • Value-based map of patient care processes • Eliminate “waste”

• Why: structured implementation produces faster, more effective results • Use of checklists in under-resourced health systems• Diffusion of effective surgical techniques across specialties• Increasing vaccination rates among health care workers• Improving evidence-based suicide assessment and treatment• Reducing unneeded anti-malarial drug treatment in Senegal• Increasing the use of psychiatric guidelines and improving patient outcomes, etc…

Inside the Toolkit:

• Stage 1: Decision Process• Assess the providers, staff, and community need• Establish the boundaries: BH provider and approach• Evaluate the impact on the practice and plan

• Stage 2: Design Process• Understand the current process of care and its challenges• Redraw the process of care with selected tactics imbedded

• Stage 3: Implementation Process• Accountability to plan• Measure results

Toolkit Applied:

•Practice 1: started co-located BHC, integrated into practice visit, referral, and return visit system•Practice 2: continued integrated BHC, with “no-visit”

design, focused on a specific patient population• Identify patients with co-morbid need via EHR• Health risk self-assessment and endorsed goals for change• Shared review of results and self-management plan• Coordinated care with multi-level care team

Practice 2: “No-visit” assessment, plan, and management• Stage 1: Decision Process• Assess: IBH already successful but unmet need of co-morbidity• Boundaries: target population must match strategic focus• Evaluate: Care Management resource available

• Stage 2: Design Process• Current process does not effectively address unstable diabetes• Parallel process to conduct new protocol for patients with A1C ≥ 8• 116 patients identified; 10 patients recruited for trial of 3 months

Practice 2: New Protocol DesignHealth Behavior Integration Clinical Protocol Case Study: Type 2 Diabetes + Depression

Electronic Health Record (EHR)Identification of Co-Morbid, Behaviorally Implicated Patients, A1C≥8

Female patient diagnosed with Type 2 diabetes with A1C results = 9 and PHQ9 = 11

Patient completion of web-based health risk assessment

Patient identifies health related risks: health behaviors and psychological problems

Automatic fax to PCP office and route to office staff for review

Patient has endorsed areas for change: Food, Beverages, Depression

Staff review of EHR data

Mid 50’s female, married, isolated, poor support, limited ability to adhere to self-care instructions, rural location, is the family food preparer with little attention to nutrition. Noted issues:

Says she has “no life,” no support, “disease will kill me” Little exercise, little social interaction, not doing injectables Positive for hypertension and depression A1C tests getting worse No identified interests; used to sew & crochet

Practice 2: New Protocol, continued….

Staff assesses with patient: interests, values, goals

PATIENT SET GOALS

Education: Injectables, meal planning, exercise Self Monitoring: Number of times walked to the mailbox each day Engagement: Behavioral Health Services for fear/despair Self-Identified Plan: Start sewing with friends

Coordinated care with multi-level care team via phone support, shared EHR documentation, and community resources

Result: Decrease in A1C, PHQ9 over time

Practice 2: Stage 3 - Implementation Process• Accountability:• Plan supported by practice and health system leadership• Limited resources for staffing and work flow redesign

• Measure:• 50% of recruited patients joined trial; 90% of those continued (9/10)• Pilot A1C improved by 0.45 points, vs. 0.19 in control, net: 0.26 (P=.64)• Adjusted for insurance, age, sex: mean A1C in pilot improved 0.41 (P=.45)• Pilot median “days between tests” was 52 days less than control (P=.19)• Providers & staff reported: better able to do jobs, with more useful tasks to

help patients (3.18 and 3.60 respectively, scaled 1 [less] – 5 [more])• Providers & staff reported: caring for these patients did not become easier

or simpler (mean survey results of 2.82 and 2.90 respectively, scaled 1 [less] – 5 [more])

Practice 2: Stage 3 – Toolkit Outcome Measures • Outcomes that scored greater than 3.0 on a 1-5(highest) scale:• Project improved the quality of patient care• Practice does a better job caring for patients than before• The behavioral health project improved how well I can do my job.• The behavioral health project resulted in more useful tasks to help patients needing

behavioral health services.• The method of conducting the behavioral health project was easy to do.• The method of conducting the behavioral health project had useful outcomes.• The Toolkit helped us make changes that were part of the behavioral health project.• I would be willing to use a similar Toolkit to make changes in other parts of the office.• I would recommend this Toolkit to other practices interested in integrating behavioral

health services.

However, the Toolkit was not perceived as:(Outcomes that scored less than 3.0 on a 1-5 [highest] scale)•Making the practice more efficient• Providing faster access to a behavioral health provider within or

outside the practice• Reducing waiting time for BH service•Making provider or staff work easier• Reducing the number of steps in helping patients who need BH

services

Toolkit Findings:• Behavioral aspects of chronic disease management can be addressed via self-

assessments, registries and EHRs• Electronic patient reported behavioral risk assessment works in primary care• Strengths:• Does not require provider/MD to respond immediately to new patient information• Assists provider/MD in responding to patient goals and care plan• Overcomes patient barriers to changing health behaviors

• Limitations:• Requires coordination of an inter-professional staff approach• Requires dedicated staff with ~1/2 hour/ engaged patient/month• Requires EHR and other infrastructure to share information and maintain contact

• Results positive, but small sample size limited the ability to achieve significant outcomes

Summary• Integration is a complex set of process changes that requires thought

and decision making at different levels of the organization• There is a robust technology of process design and implementation to

assist with the multiple levels of decisions and implementation• The Integration Toolkit addresses the quality improvement stages and

processes to move to advanced integration levels• Level of integration is an important issue and can be measured• Results from practices suggest the method is effective and generates

observable and measurable change towards integration

Future directions

• Work in process is translating user feedback to refine the toolkit• We continue to focus on populations of patients and continue to

move towards population based behavioral care• The toolkit is a key element of a newly awarded PCORI Integrated

Behavioral Health – Primary Care project

Questions and discussionConnie van Eeghen: cvaneegh@med.uvm.eduRodger Kessler: Rodger.Kessler@med.uvm.edu

Bibliography / Reference 1. Kessler R, van Eeghen, C., Mullin D., Auxier A., Macchi C.R., Littenberg B. Measuring Behavioral Health Integration in Primary Care Settings. The Health Psychologist. March 2015.2. Kessler RS. Can we really collect and USE behavioral data in primary care medical decision making? Invited Commentary on Krist et al., Annals of Family Medicine Journal Club. November 18, 2014.3. Kessler R., van Eeghen, C. Panel-based primary care: What is it and how do we achieve it? Health Psychologist. November, 2014.4. Morton S., Shih, SC, Winther, C., Tinoco, A, Kessler, RS, Scholle, SH. Health IT- enabled Care Coordination. A National Survey of Patient-Centered Medical Home Clinicians. Annals of Family Medicine. Vol. 13, No. 3, May/June 2015.5. Kessler R.S. Evaluating the Process of Mental Health and Primary Care The Vermont Integration Profile. Family Medicine and Community Health. 5:3(1) 2015.6. Kim RY., et al. Sustainability and long-term effectiveness of the WHO surgical safety checklist combined with pulse oximetry in aresource-limited setting: two-year update from Moldova. JAMA Surgery. 150(5):473-9, May 2015.7. De Groot, JJ, et al. Diffusion of Enhanced Recovery principles in gynecologic oncology surgery: is active implementation still necessary? Gynecologic Oncology. 134(3):570-5, Sept 2014.8. van Ramshorst, GH., et al. Closure of midline laparotomies by means of small stitches: practical aspects of a new technique. Surgical Technology International. 23:34-8, Sept 2013.9. Riphagen-Dalhuisen, J., et al. Planning and process evaluation of a multi-faceted influenza vaccination implementation strategy for health care workers in acute health care settings. BMC Infectious Diseases. 13:235, 2013.10. de Beurs, Improving the application of a practice guideline for the assessment and treatment of suicidal behavior by training thefull staff of psychiatric departments via an e-learning supported Train-the-Trainer program: study protocol for arandomized controlled trial. Trials. 14:9, 2013.11. Thiam, S., et al. Major reduction in anti-malarial drug consumption in Senegal after nation-wide introduction of malaria rapid diagnostic tests. PLoS ONE. 6(4):e18419, 2011.12. Weinmann, S., et al. Effects of implementation of psychiatric guidelines on provider performance and patient outcome: systematic review. Acta Psychiatrica Scandinavica. 115(6):420-33, June 2007.

Session Evaluation

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before leaving this session.

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