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Moving from Co-location to Integration: Collaboration Between a Health Plan
(Managed Care Organization) and a Federally Qualified Health Center (FQHC)
David Johnson, MSW, ASW, Director of Health Services, Anthem, Inc.Sean M. Benedict, Psy.D., LMFT, Clinical Supervisor, WellSpace Health
Collaborative Family Healthcare Association 17th Annual ConferenceOctober 15-17, 2015 Portland, Oregon U.S.A.
Session # H2aOctober 16, 2015
Faculty Disclosure
The presenters of this session• have NOT had any relevant financial
relationships during the past 12 months.
Learning Objectives
At the conclusion of this session, the participant will be able to:
• Define three components in building a collaboration between a payer and a provider.
• Identify at least two strategies to move from co-located to integrated health services.
• List three outcomes of a collaborative integrated health program
Bibliography / Reference
1. Angstman, KB, Rohrer, JE, and Rasmussen, NH . PHQ-9 Response Curve: Rate of Improvement for Depression Treatment with Collaborative Care Management 2012 ;Journal of Primary Care & Community Health 2012; 3(3) 155-158
2. Kroenke, K and Spitzer, RL. The PHQ-9: A New Depression Diagnostic and Severity Measure Psychiatric Annals 2002;32(9) 1-7.
3. Katon, WJ, et al. Collaborative Care for Patients with Depression and Chronic Illnesses. New England Journal of Medicine 2010; 363(27) 2611-2620.
4. Pratt, LA and Brody, DJ. Depression in the U.S. Household population, 2009-2012, 2014 NCHS Data Brief, No. 172: National Center for Health Statistics.
5. Waxmonsky, JA., et al Evaluating Depression Care Management in a Community Setting: Main Outcomes for a Medicaid HMO Population with Multiple Medical and Psychiatric Comorbidities. Depression Research and Treatment, 2012: Article ID 769298
Bibliography / Reference
6. Nutting, PA., et al, Care Management for Depression in Primary Care Practice: Findings from the RESPECT-Depression Trial. Annals of Family Medicine, 2008; 6(1) 30-37.
7. Whitebird, RR, et al Effective Implementation of Collaborative Care for Depression: What is Needed? The American Journal of Managed Care, 2014; 20(9) 699-708.
8. Linde, K, et al, Effectiveness of Psychological Treatments for Depressive Disorders in Primary Care: Systematic Review and Meta-Analysis. Annals of Family Medicine, 2015;13(1) 56-68.
9. Linde, K, et al. Efficacy and Acceptability of Pharmacological Treatments for Depressive Disorders in Primary Care: Systematic Review and Network Meta-Analysis. Annals of Family Medicine, 2015;13(1) 69-79.
10.Coventry, P, et al. Integrated Primary Care for Patients with Mental and Physical Multimorbidity: Cluster Randomised Controlled Trial of Collaborative Care for Patients with Depression Comorbid with Diabetes or Cardiovascular Disease. British Medical Journal, 2015; h638.
Learning Assessment
• A learning assessment is required for CE credit.
• A question and answer period will be conducted at the end of this presentation.
WellSpace Health
• Serving the Greater Sacramento Area since 1953
• Serving 35,000 unique patients a year in 13 health centers
• Over 400 employees
WellSpace Health
Services Include:• Medical, Dental, Women’s Health, Pediatrics• Behavioral Health includes: Psychiatry, IBH (PC
Consults), Psychotherapy, Group Therapy, AOD Services, Case Management, ED Navigation, Transitional Housing, Suicide Prevention.
Anthem Inc. Fast Facts
Purpose
Statement
Together, we aretransforming health care with trustedand caring solutions
51,000 associates are employed by Anthem =1,000
OUR MEMBERS
37 milliontotal medical members
1 in 9 Americans
active dollars in local communities
$45.9 millionpledged associate
giving (includingFoundation match)
$5.6 millionin grants to local and
national initiatives since 2000
$160 million
19 states $73B
14 states
BC or BCBS plan
Medicaid presence
total operating revenue
68Mindividuals
served
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Anthem, Inc. Government Business Division
• 5.2 million Medicaid members in 19 states
• 580,000 Medicare members in 20 states
• 204,000 MLTSS program members in eight states
• Older adults and people with disabilities
• Low income families
• Other government-sponsored enrollees
Anthem, Inc. affiliated health plans serve 8.1 million people in state and federal government health programs, including:
10
Why Establish Integrated Behavioral Health?
“No health without mental health” Quality of lifeMorbidity Impact on prognosis of other medical conditions
(Prevalence 2 to 3 times higher for individuals with chronic pain, cancer, diabetes, heart disease, and other chronic health conditions)
Prevalent• Up to 26% of the US population suffers from a
behavioral health disorder annually• The prevalence for any mood disorder is 9.5%
– 6.7% Major Depressive Disorder; 1.5% Dysthymia; 2.6% Bipolar I and II
Demands on physician time
Core Program Components
• Universal Screening or targeted screening• Identification/assessment of persons screening in
clinical range• Interventions—collaboration between BHC and PCP
– Health Coaching– Short-term, solution focused counseling– Medication– Referral to specialty MH
• Consistent measurement and monitoring (registry)• Psychiatric Consultation
Getting StartedHealth Plan• Collaboration• How many members by Provider• Staffing—”who owns the staff”• Training• Agreement—Contract, MOU• Finance Issues • Documentation and expected
outcomes
Health Center• Administrative Support• Introduce program concept to
staff• Review agreement• Physician champion• Logistics—space, phones, EHR
forms• Hiring process
Roles and ResponsibilitiesActivity BHC Psychiatrist Health Center Anthem
Program Planning
Review program Operational\Logistical issues
Identify Health Center.Draft agreement
Pre-implementation
Complete IMPACT Training
Complete IMPACT Training
Hire staffPhysician Champion
Training and consultation with clinic
Implementation
Screening, assessment & intervention
Consultation on complex situations
Process and procedure for screening
Reinforce best practice and treatment guidelines
Implementation Challenges
Program Launch
The path to implementation is not likely to be straight
All staff awareness
Process in place for screening—if paper and pencil forms printed, know who will administer and what to do when patient scores in clinical range
Ability to track agreed upon process and outcome measure
Implementation Challenges
Health Center• Trust• More work for everyone• EMR/EHR modifications• Not the way we practice• Patient flow and process• Location of BHC• If single payer initiative how
does program impact flows with other patients
• Lack of staff experience
Health Plan• Who supports implementation• Moving beyond “cost offset”• Role of Health Plan case
managers• Billing issues• Training and orientation for
health plan clinical services and provider relations
• If single payer, resolve that program will flow over to other payer’s members
Addressing Challenges
• Training—the model is an Evidence Based Treatment physicians can grasp
• Meet– Frequent meetings early on– Reduce to monthly meetings to review program
operations and data• Maintain flexibility and adaptability to reflect
the health center culture
Member/Patient Engagement• Response to screening• Engaging members when in the clinical range• Diamond project noted an engagement rate of
15%. Whitebird, et al 2014
• Respect project reported 68.5% engagement Waxmonsky, et al 2013
• Organizational support (screener: “do you want to speak to BHC?”)
• Physician support• Strong BHC
Moving from Co-location to IntegrationHealth Center• Philosophy, a team
approach• Parsimony—screening and
assessment • Evidence-based• Staffing• Team huddles• Documentation, EHR• Flexibility and adaptability• Outcomes and benefits
Health Plan• Philosophy, a provider
collaborative approach• Financial model—value-
based purchasing• Consultation—technical and
clinical expertise • Data sharing & care
coordination• Quality management and
outcomes
Outcomes• Improved detection and
identification of depression• Improved health services—
reduced wait time for specialty MH services
• Decreased patient severity of depressive symptoms
• Improved care coordination
Screening Program Initiation to June 15, 2015
Health Plan Start Date New Screen PHQ-9 Clinical Audit C
Sacramento CA 6/1/14 1,086 42% *
Tulare CA 11/1/14 435 26% 7%**
Maryland 6/18/13 904 34% 18%***
Tennessee 9/16/13 1,021 24% 4%
Texas 8/26/13 769 15% 4%
Total 4,215 29% 9%
• Clinic has not been able to extract Audit C scores from their EMR** Clinic only reported 25 members with Audit C screening*** MD in an HIV Clinic with higher rates for positive Audit C screening**** Total Screened for Alcohol =2,520 as this screening was added later into the program
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Severity of Depressive Symptoms
44%
27%
14%
10%
6%
Percent
Non-Clinical (0-4)Mild (5-9)Moderate (10-14)Moderate Severe (15-19)Severe (20+)
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Severity by Program Site
Non-Clinical (1-4) Mild (5-9)
Moderate (10-14)
Moderate Severe (15-19)
Severe (20+)
Total 44.0% 27.0% 14.0% 10.0% 6.0%MD 46.0% 21.0% 19.0% 11.0% 4.0%TN 46.0% 30.0% 14.0% 8.0% 2.0%TX 40.0% 45.0% 6.0% 6.0% 4.0%Tulare CA 50.0% 23.0% 12.0% 8.0% 6.0%Sacramento CA 38.0% 19.0% 16.0% 15.0% 12.0%
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Overall, a total of 1,260 members (30%) met our criteria for scoring in the clinical range with depressive symptoms. A multi-site program serving Medicaid members in Colorado screened 1,758 individuals, 36.9% scored a 10 or higher.
Member Prior Diagnosis and Treatment of Depression
Prior Diagnosis Prior RX0%
10%
20%
30%
40%
50%
60%
70%
28%
19%
64%
43%
All MembersMembers in Clinical Range
25
Depression and SUD
Alcohol Prescription Rx Illegal Drugs0%
2%
4%
6%
8%
10%
12%
14%
16%
9%
2%
7%
14%
4%
12%
Total ScreenedPositive Depression Screen
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Clinical OutcomesChanges in PHQ-9 ScoresIndex Visit to most recent
Degree of Change Number Percent
Significantly Worse (Score +5or higher) 54 7%
Worse (Score of +2 to +4) 59 8%
No Change (Change of +1 to -1) 202 26%
Slight Improvement (-2 to -4) 154 20%
Sig. Improvement (Score -5 or lower) 308 39%
Total 777 100%
The change score is based on the difference from the index visit to the most recent administration of the PHQ-9. A score of 10 or higher is considered in the clinical range for depression, the higher the score the greater the severity. A decrease in score reflects improvement.
27
Sample Response Curve PC-INSITE
Index 4 weeks 6 weeks 24 weeks 28 weeks 32 weeks0
5
10
15
20
25
30
24
15
63
6 6
PHQ-9
PHQ-9
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Sample Response Curve PC-INSITE
Index 12 weeks
16 weeks
20 weeks
24 weeks
28 weeks
32 weeks
36 weeks
40 weeks
45 weeks
02468
1012141618
13
98
1112
10 10
17
98
PHQ-9
PHQ-9
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Non-Response or Treatment Resistant Depression
• What about members who get significantly worse?• WellSpace review of 26 members in which symptom
severity increased by 5 points or more– 17 Females; 9 males– Two-thirds did not engage, but continued to return for
medical reasons– 22 of 26 meet criteria for SMI – 5 chronic pain; 2 presenting for controlled substances only– 3 of the 26 have reflected some improvement since these
data were reported
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Sustainability• Value-base as best practice• Improves the person’s experience as an active
participant in addressing health issues• Clinical outcomes—improvement in health
and well-being• Financial outcomes—physicians in clinic
greater efficiencies; service utilization of emergency department and inpatient admissions decrease
Summary
• Depression and SUD are significant factors impacting a person’s health and their health services utilization
• PC-INSITE provides services in primary care settings to specifically address these conditions
• Over 4,215 members have been screened since the launch of PC-INSITE in four states
• 30% screened positive for depression• 9% screened positive for SUD• 60% of those members in the clinical range have had at least one
follow-up contact and completed a second PHQ-9• 59% Experienced at least some reduction in symptom severity at
follow-up
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Session Evaluation
Please complete and return theevaluation form to the classroom
monitor before leaving this session.
Thank you!
PEC-ALL-1661-15