Embedded Behavioral Health in a Patient Centered Medical Home:

Jefferson Family Medicine Associates and Delaware County Professional Services

Richard C. Wender, MDAlumni Professor and Chair

Department of Family & Community MedicineThomas Jefferson University

Jefferson Family Medicine Associates - A Unique Practice

• Largest single site primary care practice in the country

–23,000 active patients who make 75,000 annual visits

• Integrated resident and faculty practice

–35 faculty (about 15 clinical FTE)

–28 residents (expanding to 30)

–5 CRNP’s

–2 Sports Medicine Fellows

JFMA: Insurance Mix

Medicaid – capitated

28%

Commerical – capitated

35%

Medicare – indemnity

14%

Commerical – indemnity

13%

Medicaid – indemnity

2%

All others8%

Behavioral Health Services – Before DCPS Partnership

Fragmentation

–Multiple insurers each with a variety of contractual relationships

–Relied largely on 800 numbers on back of card

–Jefferson Psychiatry difficult to access

–Disincentive to consultation

2008

• One of 32 Southeast Pa. practices to participate in Pennsylvania Chronic Care Commission Medical Home Pilots

–Focus on diabetes care

On January 29, 2009, Jefferson Family Medicine earned recognition as a Level 3 Patient Centered Primary Care Medical Home from the National Center for Quality Assurance (NCQA)

–The first Department of Family Medicine in the nation to earn this recognition

–Fully integrated residency and faculty practice

August 2008

• Approached by Lynne DiCaprio to consider embedded behavioral health services

• Designed co-location model which was implemented Jan 1, 2009

• Rented Jefferson space

– (Anti kickback issues must be addressed)

• Department of Psychiatry not entirely thrilled with this plan

–DCPS office is down the hall from Jefferson Psychiatry

–To their credit, Jefferson Psychiatry reached out to us to improve access

The JFMA-DCPS-Jefferson Department of Psychiatry Model

• DCPS serves as initial access point for all patients and guides patients to site that can provide care

Referral Process

• JFMA clinicians complete simple referral form with patient contact information

• Patient signs consent for JCPS to view patient record

• Form is faxed to DCPS

–They contact patient to schedule appointment

JFMA Patient Referrals Through DPCS1/1/11 – 9/30/11

Had appointment -

no show22%

Arrived and treated or referred

40%

Did not respond

(3+ attempts)38%

N=643

Keys to Success: An Option for all Insurers

• This is a 3-way partnership

–DCPS and Department of Psychiatry have complementary contracts

• Department accepts Medicaid; DCPS does not, but does have a Medicare contract

Keys To Success: A Single Venue for all Behavioral Health Referrals

• DCPS serves as navigator to get patients to Jefferson, to DCPS, or to other providers for ongoing care

Keys to Success – Patient Acceptance

• Co-location makes a big difference

– “Would you like to see our behavioral health counselor?”

– “They work right here with us”

• Staying at Jefferson helps

• Knowing the therapists by name changes the nature of referral

Keys to Success – Expanding Indications

• Easier access within the PCMH model has allowed expansion of indications for referral

–Addressing barriers to self-management

Keys to Success – Shared Problem Solving

Meeting with your behavioral health partners to make the program better works!

Now isn’t that a shocker?

Keys To Success – Addressing No-Show Rate

• Feedback from DCPS helped us be more selective with referrals

– “Don’t say yes to the referral unless you are committing to keeping the appointment”

–No-show has improved

What’s Not Working?

Access Challenges

• Co-location with an option for every patient to receive longer term care is a critical and highly valued component of the PCMH

. . .But does not ensure adequate access or partnership

Nor does it address the full scope of behavioral health needs

–Fully integrated behavioral health in the office with immediate access

–Behavioral intervention for issues that don’t warrant referral for “counseling”