Patient Centered Medical Home Project- Integrated Behavioral Health Systems

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Patient Centered Medical Home Project-
Integrated Behavioral Health Systems
Oct 12 session

Bill McFeature, Ph.D.
Director of Integrative Behavioral
Health Care Services
Southwest Virginia Community Health Systems,
Incorporated
Collaborative Family Healthcare Association
Annual Conference October 10-12, Denver, Colorado
U.S.A.
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Health Homes for Enrollees with Chronic Co morbid
Conditions

• Section 2703 of the Affordable Healthcare Act
  allows States to elect this option under the
• Medicaid State Plan. This provision is an
  opportunity for States to address the need and
  support for the enhanced integration and
  coordination of primary care, behavioral health,
  dental, and specialty mental health and substance
  use, and long term services for persons across
  the lifespan with chronic illness.

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CMS Medicaid PCMH Demonstration Project-
2012-2013

• CMS -Advance Primary Care Workgroup ( meaningful
  use measures)
• JCAHO Accredited -seeking NCQA
• Virginia Community Healthcare Association
• PCMH Collaboration Project
• Virginia Community Healthcare Foundation
• Grant- 175,000.

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SVCHS PerFORMAnce Improvement
TEAM

• PI Leadership Team meets monthly
• 1. Medical Director . Dr. Kerry Moore
• 2. Behavioral Health Director
• 3. Quality Care Analyst/Nursing Jill Talbert
• 4. TI Director Tim Lamie
• 5. Finance/Contracts Director- Brenda Harris

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NCQA-PCMH Project- Level 3

• PATIENT CENTERED MEDICAL HOME GOALS
• 1. Improve Access/Care Coordination
• 2. Improve Health Outcomes(PCP-BHC)
• 3. Cost Effectiveness (decrease in ER
• Visits and Medical Care
  Utilization)
• with patients associated chronic
• co-morbid conditions.

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SVCHS PCMH Project-Level 3

• SVCHS, Inc operates five FQHCs in extreme
  Southwest Virginia (Bristol, Meadowview,
  Saltville, Tazewell, and Troutdale) with a
  PCP-BHC ratio of 31. within each center.
• SVCHS implemented the Behavioral Health
  Consultation Model of Care in 2004 best
  Integrated BH practice within primary care.

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NCQA-PCMH Process Level 3

• - Coordinated Care between PCP-BHC
• PCMH 1 Access Medicaid Plan/Self Pay Pts.
• Patient receives immediate (1- 3 days) access to
  a PCP (medical care visit) which will allow the
  provision of same-day appointments for both a
  medical care appointment and behavioral health
  visit (15 min or 30 min) with the BHC.

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NCQA-PCMH Process Level 3

• PCMH 1 Electronic Access Meaningful Use
• A computer system with access to eCW
• 1. Practice Management System (Chronic sxs)
• 2. Electronic Health Record
• 3. Web Patient Portal
• 4. Access to Pharmacy Registry
• 5. Billing System- Carved Out BH
• Reimbursement Rates- NPI Facility

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NCQA-PCMH Process Level 3

• PCMH 1 Continuity Six Panelized/Managed Care
  Medicaid Contracts, Medicare, Commercial, and
  Self Pay.
• PCPs panelized to follow co-morbid chronic
  conditions (Diabetes, Cardiovascular,
  Asthma/COPD, Depression/Anxiety, and Substance
  Use Disorders).

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NCQA-PCMH Process Level 3

• PCMH 1 Medical Home Responsibilities
• Care Coordinator leads morning Huddle Meetings
• Care Coordinator will monitor the percentage of
  co-morbid chronic patients example- (diabetic
  with associated depression) with high frequency
  of medical visits, ER visits, hospital stays, and
  non-compliance to treatment.

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NCQA-PMCH Process Level 3

• PCMH 1 Culturally Appropriate Services
  ---Hispanic
• Southwest Virginia reflects a significant
  percentage of Hispanic migrant workers receiving
  both medical and brief behavioral health services
  receiving an interpreter.

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NCQA-PCMH Project Level 3

• UDS/HEDIS and CCNV-PCMH
• Vertical Integration Depression and
  Substance Use Practice Extracted Integrative
  Care Data
• PCMH 1 Primary Care Team Approach-
• Front Desk- (Patient Registration)
• Health Status Examination (Wt, Ht, BMI)
• Pain Scale, PHQ-2, and AUDIT-C)
• If positive PHQ-2-referred to BHC.
• If positive for AUDIT-C-referred to BHC

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NCQA-PCMH Project Level 3

• Horizontal Integration- PCP-BHC Coordinated Care
  -
• PCMH 2 Management of Patient Population
• 1. Care Coordinator/Huddle meetings -30
  min- each morning.
• 2. Screen and monitor both general patient
  population (80) and high risk chronic
  conditioned patients-- 2 or more chronic
  conditions (20) CCNV Extracted Data

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NCQA-PCMH Project Level 3

• PCMH 2 Clinical Data- Integrated Behavioral
  Health -
• eCW-Smart Forms (Diabetic(A1c), CAD (BP and
  Lipids), Tobacco Use and Dependency Practice
  Guidelines, Chronic Pain Practice Guidelines,
  Depression Practice Guidelines, and AUDIT-C.

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NCQA-PCMH Project Level 3

• PCMH 2 Comprehensive Health Assessment -
• Patient -Self Management Skills/Health
• Literacy- Primary Care Philosophy-PCP-BHC
• Objective Taking control of your health is the
  best way to maintain a healthy lifestyle, by
  working with your primary care team, you can take
  control of your body to improve your health and
  live a better life.

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NCQA-PCMH Project-Level 3

• PCMH 2 Population Management
• Integrated Behavioral Health Services-
  Preventive Care and Chronic Care Monitoring
• PCP Diagnostic Impression-- warm hand off or
  referred into BHC schedule
• Streamlined Scheduling to BHC-30 min visit
• Patient seen in exam room for 15 min visit.

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NCQA-PCMH Project- Level 3

• PCMH 3 Patient Integrated Care Plan
• PC Team - AMA Ethical Standards and Practice
• EvidencedBased PCBH Practices for High Risk
  Co-morbid Chronic Patient Population using Brief
  CBT, Solution- Focused, and BH Consultation.
• Universal Standard-Behavioral Health(PHQ-2 and
  PHQ-9) and Alcohol and Drug Screens(AUDIT-C) at
  each visit.

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NCQA-PCMH Project Level 3

• PCMH 4 Care Coordination-High Risk PCBH Groups
  -
• Care Coordinator works closely with the
  multidisciplinary healthcare team( MD, FNP, PA,
  BHC, and supportive nursing staff(LP/MA) in the
  primary care setting focusing on health coaching
  and coordination of care for high-risk,
  chronically ill patients and those with co-morbid
  conditions.

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NCQA-PCMH Project- Level 3

• PCMH 4 Psychotropic Medication Management-
  Continuum of Care -
• 1. PCP-BHC Coordinated Care General
• 2. Contract with UVA TelePsychiatry - for CMI
• patients, stable.
• 3. Triage with local CSBs for specialty mental
• health services, CMI, unstable.

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NCQA-PCMH Project Level 3

• PCMH 4 Provide SelfCare and Access to Specialty
  Mental Health Services for Major Psychiatric
  Disordered Patients, Unstable
• WE ARE WORKING ON IToffering Office
• Space, donuts, we lure CSB clinical case managers
  to the clinic.

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NCQA-PCMH Project- Level 3

• PCMH 5 Extracted Integrated BH Data
• Utilizing Smart Forms that capture Integrated
  Care Data (co morbid medical and behavioral
  health conditions).
• Extracted Integrative Care Data in
  coordination
• with CCNV- governing body oversees
  credentialing, MCO contracts, and performance
  measures analysis.

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NCQA-PCMH Project- Level 3

• PCMH 6 Measure and Improved PCP-BHC Coordinated
  Care Performance Data -
• 1. Psych Dx rate of General Patient
• Population - 20.
• 2. Patient Cycle Time (lt45-50 min for PCPs
• distribution)- quick access for BHC services.
• 3. Behavioral Health Program Analysis (130-
• 160 Monthly BHC Encounter Rate using ACG.

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ACG System Illness Burden and Pricing of
Bundled Service Product

• The ACG is a packaged software that uses the
  diagnosis codes and pharmacy data, to categorize
  patients by level of sickness. For instance,
  patient diagnosed with Diabetes Mellitus ( A1c-
  8.1), uncontrolled, Hypertension, BMI of 39, and
  (LPN)- PHQ-2- yes, referred to BHC- PHQ-9- based
  on 2 visits-score of 17 to determine level of
  patient complexity determining
• a value score- 2014- integrative care data.

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• Questions?
• THANK YOU!

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