Integrated Primary Care Program

1

• Integrated Primary Care Program
• New England Rural Health Roundtable
• Maryagnes Gillman
• October 30, 2009

Sacopee Valley Health Center
2
Sacopee Valley Health Center

• Location - Porter, Maine
• Opened in 1976
• Federally Qualified Health Center
• Patients 4,300
• Encounters 17,000
• Total staff 45
• Serves 12 rural towns in 4 counties two states
  (Maine New Hampshire)
• Service area population of 20,500

Sacopee Valley Health Center
3
SVHC
Sacopee Valley Health Center
4
Sacopee Valley Health Center
5
Sacopee Valley Health Center

• 3 family practice physician 2.25 FTEs
• 1 pediatrician 1FTE
• 2 physician assistant 1FTE
• 1 family nurse practitioner ½ day/week
• 1 behavioral health consultant - LCSW
• 1 care manager BA
• 1 MMCPHO care manager - RN
• 1 pediatric psychiatrist- one day/week
• 6 mental health program staff

Sacopee Valley Health Center
Sacopee Valley Health Center
6
Programs Services at SVHC

• Family Medical Care
• Pediatric Psychiatry
• Mental Health Counseling
• Substance Abuse Counseling
• Integrated Behavioral Health
• Nutrition Counseling
• Podiatry
• Prepared Childbirth Classes

• Community Health Education
• Care management
• Optometry
• Family Planning
• Social Services Coordination
• Fee Discount Program
• Patient Assistance Program (for chronic meds)
• MaineCare (Medicaid) Enrollment Assistance

Sacopee Valley Health Center
7
The beginning

• Sacopee Valley Health Center was founded in 1976,
  and had co location of mental health services
  beginning in 1978 with
• Psychiatric Social Worker
• Alcoholism Counselor
• Drug Abuse Counselor
• Contracted with York County Counseling Services
  (became Counseling Services, Inc.)

Sacopee Valley Health Center
8
1978-2005

• Through the years there were several LCSWs and
  clinical psychologists who worked at SVHC under
  contract.
• The first clinical psychologist employed by SVHC
  was in 1997, and Dr. Jeffrey Krebs assumed that
  position in 1999.

Sacopee Valley Health Center
9
Co-location at SVHC

• This was the model used until 2004 when we began
  to look at a more integrated model after a staff
  member heard a presentation by Kirk Stroshal.

Sacopee Valley Health Center
10
Kirk Stroshal

• BPHC funded 2 day site visit to SVHC in Fall 2004
• Trained all staff in the rudiments of Integrated
  Primary Care

Sacopee Valley Health Center
11
2004

• Work group formed to study viability of
  Integrated Primary Care at SVHC
• Work group members from every department of the
  Health Center
• Goal clinical efficacy and financial/fiscal
  viability

Sacopee Valley Health Center
12
Work Team 2004

• Director of Mental Health Services
• Finance Billing Staff
• Medical Director
• Director of Allied Health Services
• Front Office Staff
• Administrative Secretary
• Executive Director

Sacopee Valley Health Center
13
Integrated Primary Care at SVHC

• Based on the Strosahl model of integration
• Stroshal model utilizes a behavioral health
  consultant
• 1-3 consult visits in typical case
• 15-30 minute visits to mimic primary care pace
  and promote visit volume
• Chronic condition pathways may require additional
  protocol driven visits
• Uses classes and group medical appointments to
  increase volume depth of intervention
• High risk, high need patients seen more often as
  part of team based mgmt plan
• 2005 was kick off - after planning year

Sacopee Valley Health Center
14
2005

• Behavioral Health Consultant began seeing
  patients in September 2005
• Needed to learn the role lots to unlearn
• Focused on self management and activation
• Evidenced based tool kit
• What do you think you can work on?
• Primary Care providers needed to refer patients
  to be seen
• Using Codes for Health and Behavior
  Assessment/Intervention 96150-96155
• Using PHQ9

Sacopee Valley Health Center
15
2006

• Developed standing orders for patients
• HTN BP gt140/90
• Diabetes HbA1c gt7
• Depression PHQ9 gt9
• Patient satisfaction with program
• Tracking provider referrals
• Added classes to program
• Stress reduction
• Living well with ongoing conditions
• BHC is housed in medical wing of the building
• BHC schedule is on primary care provider monthly
  schedule
• Member of primary care provider team

Sacopee Valley Health Center
16
2007

• Program continues to evolve
• Targeted focus on diabetes
• New providers on staff need to learn process
• Medical providers went live with EMR
• BHC using EMR exclusively for notes
• Doing cold calls to patients while they are
  waiting to be seen
• PHQ9 use continues
• BHC now a direct report to medical director

Sacopee Valley Health Center
17
2008

• MeHAF funding awarded for program expansion
• Add additional screening tools DUKE, SOAPP, MDQ,
  COMM, PSC, GAD7, CAGE-AID and PC-PTSD
• Use laptops for patients to enter their own data
  regarding screening tools
• Add care management functions to program

Sacopee Valley Health Center
18
2008 Continued

• Engage the shadow health care network
• Use libraries as a spread strategy
• Establish a patient and family council focused on
  integration and care delivery

Sacopee Valley Health Center
19
2009

• Problem Solving Treatment Primary Care
• Huddles
• Warm hand offs
• Curbside Consults
• Screenings
• Standing orders
• Referral trolling
• Role differentiation

Sacopee Valley Health Center
20
Primary success of PST is the patient learning
new skills to approach problems.Give a
man a fish he eats for a day teach a man to fish
and he eats for a lifetime.
Sacopee Valley Health Center
21
Project Team 2009
Donna Burke
Marty Braga
Jeff Ray
Jeffrey Krebs
Maryagnes Gillman
April Clark
Amy Richardson
Sacopee Valley Health Center
22
Role DifferentiationBHC Care Manager MH
Counselor

• BHC billable 11 visits
• Care Manager phone call follow-ups, shadow
  health care network, libraries, meets with new
  patients, CPEs, well child checks, Pt and Family
  Council
• MH Counselor traditional mental health
  counseling

Sacopee Valley Health Center
23
2005-2009

• Ongoing staff training
• During interview process for potential hires
• All staff meetings
• Individualized team meetings
• Methodologies have included
• Written materials
• Didactic presentations
• Role play
• Outside experts

Sacopee Valley Health Center
24
Philosophy of Integration

• Holistic
• Routine part of care connecting head to body
• Focused on wellness
• Self management
• Communication

Sacopee Valley Health Center
25
Patient Satisfaction
Sacopee Valley Health Center
26
Patient Satisfaction

• Collected since the beginning.
• Has evolved based on our experience and
  information learned as part of MeHAF Quality
  Counts project.

Sacopee Valley Health Center
27
New Patient Satisfaction SurveyImplemented Sept
1, 2009Give us a Grade
Sacopee Valley Health Center
28
GIVE US A GRADE Integrated Primary Care

• The staff at this facility works well together
  and communicates with each other about my care.
  3.77 A-
• I receive respect from the staff that provides my
  care. 3.85 A-
• I am involved in the development of my plan of
  care. 3.81 A-
• As a result of receiving integrated care, I
  believe my health has improved and I am taking
  better care of myself. 3.69 B
• As a result of receiving integrated care, I am
  better able to do my usual activities, such as
  work or school and recreation. 3.82 A-

Sacopee Valley Health Center
29
Provider Satisfaction
Sacopee Valley Health Center
30
Quality Counts PilotProvider Satisfaction

• As a result of our efforts to integrate clinical
  care
• Worsened Stayed the Same Improved
• 1 - 2 - 3 - 4 -
  5
• My job satisfaction has 4.63
• The care provided to our patients has 4.63
• Communication between the medical and behavioral
  staff regarding our patients plan of are has
  4.63

Sacopee Valley Health Center
31
Results
Sacopee Valley Health Center
32
Self Management Goal Setting

Jul 09 Number of pts with depression increased
from 562 patients to 813 patients thus the
decrease in SMG
Sacopee Valley Health Center
33
UDS Measure 2009 BPR

• By 2010, increase of adults patients, age 18
  and older who have completed one PHQ9 from 12.1
  (2008 baseline calendar year) to 25.
• Current results Sept 2009 18.3

Sacopee Valley Health Center
34
August 2009

• Milestones
• Care manager meeting with new patients
• Care manager meeting with patients scheduled for
  CPEs and Well Child Checks
• Patient and Family Council first meeting
• BHC and Care Manager meeting weekly with Medical
  Director
• Revitalized classes Zucchini Fest

Sacopee Valley Health Center
35
Zucchini Fest
Sacopee Valley Health Center
36
Patient and Family Council

• First meeting held August 26, 2009
• Council has seven members
• Meetings facilitated by our Care Manager and
  Health Educator
• Project specific assignments lobby
• Next Project How would patients liked to be
  surveyed about satisfaction?

Sacopee Valley Health Center
37
Billing

• LCSW providing this service
• Using 96150-96155
• Health and Behavior Assessment/Intervention Codes

Sacopee Valley Health Center
38
Sacopee Valley Health Center
39
Speed Bumps

• EMR Implementation
• Classes
• Paradigm shifts medical providers BHC/Care
  manager and patients
• Segue scripts adherence
• Over optimism warm hands offs
• Cold calling difficulties
• Role clarification
• BHC 4 visit limit
• Not Mental Health crisis service

Sacopee Valley Health Center
40
Next Steps

• Pain Program
• Schedule II medications
• Benzos
• Sleepers
• Insomnia - CBT

Sacopee Valley Health Center
41
We believe that we have come a long way in
putting head back on the body and treating the
whole person!
Sacopee Valley Health Center
42
Questions?
Sacopee Valley Health Center
43

• Sacopee Valley Health Center
• 70 Main Street
• Porter, Maine 04068
• Mailing address PO Box 777
• Parsonsfield, ME 04047
• Contact
• Maryagnes Gillman mgillman_at_svhc.org
• 1-207-625-8129 ext 164

Sacopee Valley Health Center