Integrated Health Services at Winters Healthcare FoundationJ. JAVIER LUNA, PH.D. DIRECTOR OF INTEGRATED HEALTH SERVICESWINTERS HEALTHCARE (FQHC)
“Its very hard to do integrated care and still think of “mental health” and “physical health.” The categories just begin to break down because they don’t describe the way people present. They don’t describe how problems form over the years.”
Alexander Blount EdDUMASS The Center for Integrated Primary Care
Winters Healthcare FoundationSmall Rural Clinic (FQHC) in Northern California3000 patients approximately served annuallyBHC services since Oct 2012Integrated Health Coaching Program since Oct 2013Average of 3-4 Primary Care Providers in clinic
Integrated Health Services includes our behavioral health consultant service and health coaching program1 Behavioral Health Consultant (BHC) and 2 Integrated Health Coaches (IHC)Implementation of BHC model started in October of 2012Health Coaching program started in October of 2013
Integrated Health Services at WHF
Models of integration include Primary Care Behavioral Health (PCBH or BHC), Collaborative Care (IMPACT Model), SBIRT
Programs are site specific efforts to integrate primary care and behavioral health services
Population Penetration is the degree of in-reach into the general population
Before we get started….Some Vocabulary
BHC is a member of the primary care team (not specialty care)Provides consultations, (not “therapy”)or “counseling”- avoid these terms)◦Brief visits, limited and flexible follow-ups◦Prompt feedback to PCPGoal is immediate access for any and all health issues-not just MH disorders and crisis mgmt!! Emphasizes population mgmt, psychoeducationFocus on improving QOL and health care
The PCBH or BHC Model
Integrated Health Coach (IHC) is a member of the primary care teamCoach patients with chronic conditions to improve their self-managementUse various Motivational Interviewing strategies, behavior change techniquesFunctionally work like BHC’sThink of a on-demand Health Educator, Nutritionist Diabetes Educator, Patient Navigator, Panel Manager, all in one!!!
Health Coaching Program
To serve our primary care teams and patients with immediately-accessible
behavioral health, chronic disease, and self-management support through timely,
flexible, and innovative services
Mission of Integrated Health Services
Population FocusIntegrated GeneralistProvide services on-demand in real timeOperate with assumption that patients will not come backUse vertical and horizontal strategiesFlexible schedule template for follow up visitsUtilize registry and other care management strategiesUse simple data design and collection strategies
Core Tenants of Integrated Health Services
Stepped Care
Step 2: Step 1 plus + Stress, Signficant Barriers, Behavioral
Issues, Medical Complexity, History of Mental Health issues
HealthCoaching
BehavioralHealthConsultation
Horizontal vs. Vertical InterventionsHORIZONTALNot targeted Customers present with a range of concerns Meet them where they are at Help to improve their overall health Ex: Customer presents with chest pain, medical rule out, focus on stress
VERTICALTargeted Work with specific subpopulations Targeted interventions for these populations Define treatment protocols and clinical guidelines Ex: Depression screening and follow-up
BHC and IHC Referrals Typical psych issuesChronic PainSmoking cessationObesity/weight managementSleep disordersDiabetesHeadaches
Hyperlipidemia and hypertensionFatigueParenting and pediatric behavioral issuesSexual healthMedication/treatment compliance
No caseloadLess “Assessment”Faster paceTransparencyWorking as part of a teamBilling issuesAmbigous clinical situationsProfessional identity Open Schedule/Varied Day
Challenges for New Integrated Professionals
Clinical (e.g., pre-post, PHQ9, GAD-7)
Financial (e.g., cost per pt or cost per visit/Revenue, Cost of program/unique patients or total visits
Process (e.g., population penetration, depression and alcohol screening)
Satisfaction (e.g., provider or patient satisfaction)
Metrics
Behavioral Health
53
71
59
3745
63 65
21
11
2113
1819 1621
9
75
10093
51
0
20
40
60
80
100
120
Feb March April May
Unique Pts Per Month WHO BH Scheduled WCC Visits Total Visits (WCC included)
Population Penetration (Behavioral Health)
21%
26%
21%
0%
5%
10%
15%
20%
25%
30%
2013 2014 2015
Health Coaching Program
64
84
4146
2833 35 38
13 11 70
105
128
83 84
0
20
40
60
80
100
120
140
Feb March April May
Same Day Visits Scheduled Visits Total Telephone Vists Total Touches
Scheduled vs. WHO’s (Behavioral Health)
654
539
181
228
0
100
200
300
400
500
600
700
2013 2014 2015
Warm handoffs Scheduled
Model Fidelity (Behavioral Health 2015)
296 296317
124
154
24
0
50
100
150
200
250
300
350
Visits Patients
Chart Title
1 2-4 5+
Provider Satisfaction
50%50%
All things considered, how satisfied are you with having BHC services in your clinic?
Completely Dissatisfied
Very Dissatisfied
Somewhat Dissatisfied
Neither Dissatisfied Nor Satisfied
Somewhat Satisfied
Very Satisfied
Completely Satisfied
Provider Satisfaction
Robinson & Reiter.Behavioral Consultation and Primary Care: A Guide to Integrating Services, 2nd Ed
Collaborative Family Healthcare Association (CFHA)
Helpful Resources
J. Javier Luna, Ph.D.
Thank you!