Introduction to Integrated HealthChristine Hunsberger, M.Ed, NCC, LPC
Holly Karalus, MSW, PCHA
Carolyn Lewis, PsyD
Stacey Marie Little, MA
Beth McAlister, RN, BSN, MSHA
Donald Thompson, PhD
www.nhsonline.org
Introduction to Topic and Panel
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Rates of Chronic Physical Illness
among Individuals with SMIPeople with SMI die, on average, 25 years
earlier than the general population
Increased mortality and morbidity are largely related to preventable conditions
Cardiovascular Disease
Diabetes, respiratory diseases, infectious diseases
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Higher Rates of Risk Factors
Smoking
Alcohol Consumption
Poor nutrition/obesity
Lack of exercise
IV drug use
“unsafe” sexual behavior
Residence in group care facilities
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Causes of Vulnerabilities
Homelessness
Trauma
Unemployment
Incarceration
Poverty
Social isolation
Impact of psychotropic medications
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Impact to Access to Health Care
Patient Factors
Provider Factors
System Factors
Overuse
Underuse
Start with Assessment
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Physical Health Screening Tools
Physical Health Assessment-
Reviews both overall physical and mental/behavioral health
concerns
SHOT- Shared Health Online Tool-
Documents number of contacts with wellness nurse, health
navigator, PCP, BMI, tobacco usage, substance abuse concerns
and if the self management toolkit is being used
WOOT- Wellness Outcomes Online Tool
Reviews the 8 domains of wellness
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Health Risk Screening Tool-HRST
A web-based instrument
Screens for health risks associated with a wide variety of disabilities
Provides information about the critical planning component of
health risk.
Ensures health risks are identified, managed, and planned for in the
person centered planning process.
Provides population-wide monitoring and oversight capability on a
wide variety of critical health and behavioral issues
Data trending, health tracking, self auditing and retrospective
analysis
Specific Programs and
Interventions
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Behavioral Health Liaison
Wellness Nurse as part of Targeted Case Management
Department Responsibilities
Physical Health Screenings
Connection between PCP/specialists and
Psychiatrist/Outpatient Department
Attends PCP/specialist appointments
Provides Smoking Cessation classes
Developed Personal Wellness Plans
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Supports- Peer Wellness Coaching
Peer Specialist Trained as Wellness Coaches
Create Wellness plans with individuals in one of
the 8 domains of wellness
Uses Wellness Toolkit to assist with goal
development
Coordinates with Wellness Nurse
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Cap Region Nurse Navigator
Requirements
chronic health condition, be over the age of 18, and receive Behavioral Services at NHS Capital Region
Services provided
Health Education
Assessments
Person Centered Service Plans
Referral Support and Collaboration
Transportation
Medication Management
Routine screening reminders
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Wellness Recovery Teams
A team of professionals working together to support an individual in
the community to meet their identified wellness goals to include
both Behavioral Health and Physical Health Illnesses
Administrative Navigator
Behavioral Health Navigator (Masters Level)
Nurse Navigator (Registered Nurse)
Admission Criteria:
Severe and Persistent Mental Health Diagnosis
18 years of age or older
Co-occurring physical health illness
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Wellness Recovery Teams
Length and frequency of service depends on the needs
of the individual
Teams provide outreach and coordination with all
physical health and behavioral health providers
involved with the individual in care.
Teams assist individuals in reaching their wellness goals
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Wellness Recovery Teams
Outcomes
• Decreased utilization of crisis services
• Increase in overall health, decrease in physical
health complications
• Decrease in use of emergency rooms
• Reduction in hospitalization for both behavioral
health and physical health
• Increased satisfaction and quality of life
Lehigh/Northampton County Team
Montgomery County Team
Montgomery County HCHC
www.nhsonline.org
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Health Choices Health Connections
Regional pilot program in PA
SMI and co-occurring physical health concerns
Designed with key concept of recovery
Members encouraged and empowered to work as part of
a team
Navigators focus on an individual’s whole health
physical health needs, mental health needs, and social
support needs.
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What do HCHC Navigators do?
Create a whole health treatment plan that is
individualized for each consumer
Make sure each individual has a Primary Care Provider
Focus on each individual’s total wellness
Help individuals recover and become resilient
Support individual’s independence
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What Are Specific Interventions?
Educating individuals and family/friends
Offering emotional support or assistance in finding
outpatient services to address mental health needs
Helping with medication management
Linking individuals with other community resources that
may help them stay on track with treatment or improve
their quality of life
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HCHC Specific Interventions
Assisting in communication with doctors and acting as a
liaison with other medical professionals
Offering aid in setting up and getting transportation to
appointments
Explaining insurance issues and helping with paperwork
Providing basic nutritional advice; helping individuals
learn to food shop on a budget
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What Are The Benefits?
Improved understanding of medications.
Improved self-management and wellness strategies
Development of improved relationship skills.
Increased confidence and an understanding of how to
negotiate and communicate with health care providers.
Increased coordination of care.
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What Makes the Montgomery
County Team Unique?
Team approach
Staffing
Transportation services
Collaborative meetings
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What Makes the Montgomery
County Team Unique?
Use of the Consumer Health Inventory (CHI)
Screens, monitors and assesses the progression of
health problems and concerns
Follow-up administrations can inform about changes
in a person’s health and well-being.
Tool of communication between the Navigator and the
individual.
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What Makes the Montgomery
County Team Unique?The creation of preferred provider list
Local medical professionals that work best with the
population of individuals we serve
Allows the building of relationships with doctor’s
offices which increases continuity of care
Includes cardiologists, dentists, dermatologists,
nutritionists, podiatrists, urologists, Ob-Gyn, etc.
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Most Common Areas of
InterventionDepression
Bipolar Disorder
Stress, Anger concerns, and Anxiety
Diabetes
Hypertension
Heart Disease
Drugs and Alcohol
Poor Nutrition
Exercise and Lifestyle Needs/ Weight loss & Weight gain
Pregnancy
Tobacco Cessation
Health Home with Integrated
Primary Care
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Co-located Primary Care
Fairmount Primary Care• Federally Qualified Health Center satellite,
• History of serving individuals in poverty and
insured through publicly funded means - Medicaid,
Medicare, etc.
• Invested in developing integrated primary and
behavioral healthcare.
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Staffing of Primary CareSharon Hill Medical
Primary care staff on-site at NHS 5 days/week
Medical Director - family practice physician
Nurse Practitioner/Physician Assistant
Medical Assistant
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On-site Pharmacy Services
Life Tree Pharmacy services available to all
participants
Coordination of medication therapy with
prescribers and other professional staff
Immediate medication prescriptions fills
Medication therapy adherence monitoring
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Staffing of Integrated Care Model Health Home Team consists of:
Participating individuals in recovery
Psychiatrists
Primary care professional staff (Fairmount)
Nurse Navigators (RN on each Adult BCM team or
Medical Assistants in Outpatient program)
Care Managers (Blended Case Managers)
Peer Wellness Coaches
InSHAPE Health Mentors (fitness trainers)
Yoga
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Integrating Care
NHS/PCP leadership team meets every other
week.
NHS supervisors trained in integrated care
NHS case managers trained as care managers
NHS nurse navigators on each Adult BCM
team
NHS Peer Wellness Coaches
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Integrating Care
Weekly care coordination meeting with on-site
primary care practice or virtual meeting with
community based primary care practice.
Shared access to EHRs for those mutually
served.
Shared collaborative care plan.
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11/18/16
NHS DELAWARE COUNTY
CARE COORDINATION MEETING MINUTES Date: ___________
Care Coordination Meeting Attendees:
Indentifying and Diagnostic Information Staff Involved in Serving Individual
Name of Individual Served: Birthdate:
Behavioral Health Diagnoses:
Physical Health Diagnoses:
Psychiatrist:
Primary Care Physician/CRNP/PA:
Nurse Navigator/FACT Nurse/OP Med Asst:
Blended or FACT Case Manager:
MH Therapist:
D&A Therapist:
Psychiatric Rehabilitation:
Peer Wellness Coach:
Residential Program:
Issues of Concern and/or Successes
1.
2.
3.
4.
Medication List Action Plan
Behavioral Health:
Physical Health:
Action(s): Responsible
Parties:
Due
Date(s):
11/18/16
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Integrated Care Supports
Pharmacy providing medications at time of
visit
Smoking cessation program
Whole Health Action Management (WHAM)
groups
InSHAPE program
Health Event sessions provided monthly
Lunch and Learns
Annual Health Fair open to community
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Integrating Care
Community-based primary care practices
Nurse navigators key to communication
Care coordination through Health Information
Exchanges - NHS Delaware County was one of
the first three behavioral health members of
HealthShare Exchange of Southeastern
Pennsylvania (HSX).
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Role of MCO in Integration Effort
Magellan Behavioral Health
• Supportive of effort throughout
• Agreed to expansion of nurse navigator staffing
• Worked with NHS to develop psychiatric
consultation procedure code and reimbursement
rate
• Conducting the analysis of hospitalization rates as
an outcome indicator for the health home
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Summary
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Questions?