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Operationalizing a Robust Integrated Care Team Model:A case study of one CHC’s experience in amplifying
behavioral health in primary care
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Introducing Our Speakers
Amy FeimerCEOHunter Health
Jessika CooksRN BSNHunter Health
Kaitlin Boger EdD, LMSW, LMACHunter Health
Amanda LaramieProject ManagerColeman Associates
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Hunter Health
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Hunter Health
Began providing mental health and substance use disorder services through collaboration.
1987 1993
Hired full‐time LSCSW (still with us today) and moved mental health services onsite.
1996
Substance use disorder services grew into a licensed outpatient treatment center.
2017 2018
Hired Director of Integrated Care (Q1) and an Integrated Care Consultant (Q2). Started seeing patients with medical provider.
Hired two additional Integrated Care Consultants to expand support to include evening hours and dental.
Hired two additional Integrated Care Consultants (Q4). Expanded to two satellite clinics.
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Vision for Integrated CareProvide on‐demand/real‐time access
Reduce barriers (time, expense)
Drive change with chronic conditions
Improve employee engagement
Serve our mission
Transform clinic customer service culture
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Implementation, Take 1Wins• Over the course of 2017 and 2018, ramped up integrated care services quickly. • Took the ‘just do it’ approach vs. formal project plan
• Added a total of five integrated care consultants in addition to the Director of Integrated Care.
• Significantly increased access to behavioral health services.Behavioral Health 2016 2017 2018
Patients 74 604 2,697
Visits 449 1,126 5,576
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Implementation, Take 1Gaps• While the “just do it” approach worked with two integrated care consultants, gaps began to show as we ramped up staff and patient visits
• Key issues included:• Variability between care teams in terms of who used integrated care consultants (based on provider interest vs. patient need)
• Workflow processes hadn’t clearly defined roles and responsibilities of care team members such as Medical Assistants and Nurses
• Integrated Care Consultants were being pulled in too many directions, couldn’t get charting and notes done during work hours, unable to provide appropriate follow up for patients
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Implementation, Take 1
EmployeeEngagement
41stPercentile(2017 survey)
Cycle Time
66 minutes (average w/o charting time)
?(est
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Redefine the Care Team
Create (and document) new
workflow
Create an oversight structure to validate new systems
Implementation, Take 2 In June 2018, with the help of the Coleman Associates, we took a step back and refocused on operationalizing behavioral health into our workflow.
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Redefine the Care Team
We clearly defined our care team model to include: • Medical Provider (1 FTE)• Nurse (.5 FTE)• Medical Assistant (1 FTE)• Integrated Care Consultant (.5 FTE)
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Redefine the Care Team
Provider
Provider
Provider
Provider
MA
MA
MA
MAICC ICC
Nurse Nurse
Care teams sit together in “team pods” to improve collaboration and communication.
Sample “Team Pod”
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Create (and document) New Workflow
Visit prep
Huddle
Quick start30 second report
Cuddle
Implemented Coleman Associates’ “Team Dance” workflow.
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Create (and document) New Workflow
Key Team Dance benefits:• Designated the Medical Assistant as the
“shepherd” for the whole care team, including the Integrated Care Consultant.• ICC no longer had to manage their own
schedule, they just had to “follow” their shepherd’s directions.
• Quick Start‐ing with the MA and the ICC reduced duplicative questions
• 30 Second Report empowered MAs to engage ICCs
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Create (and document) New Workflow
Level 1
Threatening behavior to
self & others
Suicidal
Behavioral Medications not Working
Uncontrolled/Initial
MAT/Pain Management
Renewal
Level 2
Odd/Change in Behavior
Present Domestic Violence/Trauma
Behavioral Treatment Planning
Initial Medications
Significant Increase in
A1C
Level 3
High A1C
Positive Drug/Alcohol‐Smoking Cessation
High Risk Sexual
Behavior
Negative Impact in Life Events
Level 4
Stable, recent
medication start f/u
Past Behavioral Diagnosis
Past domestic violence
Homelessness
Stable MAT pain management
Level 5
Stable
Create standard procedures to address: • When an ICC
should see a patient
• How to prioritize patients to ensure highest risk patients are seen
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Created infrastructure to ensure oversight and validation of new processes:• Initially, weekly DPI meeting; recently incorporated into monthly Clinical Leadership Meeting• Plan rollout to additional care teams/sites • Implement validation tools (daily, weekly, monthly, quarterly) to maintain focus and hardwire new processes
• Review performance data (e.g. Cycle Time, Same Day Charting)
Validate New Systems
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Hunter Health TodayEmployee Engagement
48% 66% 71%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Employee Engagement
2017 2018 2019
89thPercentile
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Hunter Health Today
6569
65 67 6366 64
69
63 65
595658 55 57 53
5053
50 48 46 46 46
0
10
20
30
40
50
60
70
80
October November December January February March April May June July August September
FY18 FY19 Target
Sites converted to new Rapid DPI workflow.
Patient Access – Cycle Time (includes ICC time during visit)
As of June 2018, Cycle Time includes charting
time, now 99% same day.
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Hunter Health Today
60.3%
52.8%
47.7%43.8%
40.7% 39.0%36.6% 36.1%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
2018 2019
Poorly Controlled Diabetes
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Success Story
“Thank you for caring about my overall health and wellbeing.”
Dental Patient
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Managing Complex Change
• Coleman’s Rapid Testing Methodology • Start small in scope and then scale• Market Diffusion Theory
• Behavior Change Methodology• Coaching helps staff adopt new habits• Internal Coaching Training• “Give a man a fish, you feed him for a
day, teach a man to fish and you feed him for a lifetime.” – Lao Tzu
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Questions
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