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TRANSCRIPT
8/23/2017
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Behavioral Health Integration for
Chronic Disease Management of
Depression and Diabetes
Final Report Out Webinar
August 22, 2017
Today’s Moderators
Madhana Pandian
Associate
Deann Jepson, M.S.
Co-facilitator
8/23/2017
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To participate
Use the chat box to communicate with other attendees
Use the question box to send a question directly to the presenters.
Disclaimer: The views, opinions, and content
expressed in this presentation do not
necessarily reflect the views, opinions, or
policies of the Center for Mental Health
Services (CMHS), the Substance Abuse and
Mental Health Services Administration
(SAMHSA), the Health Resources and
Services Administration (HRSA), or the U.S.
Department of Health and Human Services
(HHS).
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Behavioral Health Integration for
Chronic Disease Management of
Depression and Diabetes
Final Report Out Webinar
August 22, 2017
Impact of Social Determinants of Health (SDOH) on Diabetes and
Depression
Sanford Health
Jeff Leichter Ph.D., L.P Dr. Craig Uthe
Brittany Jaehning BSN, RN Nicole Velgersdyk MS,LPC-MH,QMHP,NCC Sarah Prenger BS, RN, CJCP Jill Swenson BSN, RN, CCM
Allyson Kugler, LSW Wendy Barta , BSN, CCM, CCTM
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Goal and Process
Goal: Examine the relationship between SDOH, Diabetes and Depression by identifying variables affecting their care.
• Integration of LSW into rural clinic
• Integration of SDOH questionnaire into patient care workflow
• Defining targeted population
• Gathering data for baseline
Building Upon the Project
• Rolled out the SDOH questionnaire to our pilot group. Positive screens referred from provider to LSW in a “warm handoff.”
– Total surveys thus far: 48
– Pilot panel size: 165
• LSW calls diabetic patients from registry to identify any needs
• Integration IHT telehealth service into workflow
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Results
• Positive patient stories
• Preliminary data from our pilot group shows improving diabetic quality scores, as well as depression scores.
Next Steps
• Roll out workflow to other providers within Wahpeton Clinic
• Utilize IHT telehealth services when appropriate
• Expand concept to other Sanford locations
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Impact
• Patients
– Improved diabetic care
– Improved depression care
– Improved quality of life (recognizing biopsychosocial needs)
• Providers
– Improved quality scores for patients with depression and diabetes
– Increased utilization of referral sources to improve overall patient experience
• Community
– Collaboration between Sanford and local/regional resources
Questions?
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Advantage Health
Centers: Healthier life
LaKreese Johnson, Crystal Bell, Wayne White, Jasmine
Bridgefourth
What’s our goal and work plan steps
• Goal: Assist patients in developing and utilizing skills to stabilize diabetes and assist in identifying s/s depression and substance abuse issue
• Action Steps:
. Identify Diabetes Education Group to provide classes.
• Identify patients to participate in diabetes educational classes.
• Gather data for target groups baseline participation.
• Identify patients diabetes diagnosis and Hemoglobin A1C testing
• Utilize Patient stress questionnaire (PHQ-9, GAD-7, Audit and PC-PTSD) screening tests to identify depression and substance abuse.
• Incorporate screening into Diabetes Education with emphasis on how Depression can affect Diabetes
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What did we learn?
• Recently lost our “in-house”
Diabetes Educator and working to
identify an individual to receive
training
• Identified community partners to
facilitate Diabetes Education/
Cooking Course
• Identified 2 Community Health
workers to contact patients and
advertise Educational classes
• The CHWs will also remind
providers to inform patients about
the Diabetes Education Course
• Delayed start of Project until 9/14
due to community partner inability
to start on identified start date
Results
• Pending Start Date 9/14
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Actions
• Definitely recommend having a Diabetes Educators on Staff. Community
partner Diabetes Educator resigned. Our previously scheduled start date
for Healthier lifestyle 7/4/2017
• Work with all Disciplines ( OB/GYN, Social Work, PCP, Behavioral Health
and Administration)
• This can also be used as a reengagement project for the noncompliant
patients
Results
• Currently the process of preparing for the project has stressed the
importance of engaging all disciplines to encourage participation
• Assist PCP is encouraging patient involvement
• Involve BH providers involvement
• Project to start 9/14
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Questions?
Diabetes and Depression Project
The body and mind are already integrated. How can we integrate our treatment?
Photo by Sander van der Wel from Netherlands / CC BY-SA 2.0
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The Plan
• Create a multidisciplinary team for the project
• Research and select a curriculum
• Select the trainers and set the dates for the course
• Obtain a fresh list of all clients with Diabetes and Depression symptoms and give them a call
• Obtain baseline measures for both depression and diabetes
• Facilitate the course
• Measure the outcomes
• Plan for the future
The CourseDiabetes Empowerment Education Program DEEP
Recruiting Participants
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Barriers and other
factors
Outcomes
Stan Sorensen, [email protected]
• Completed the project on schedule
• Improved relationship with patients
• Recruited one client for full involvement in the Healing Center
• Decreased level of depression of participants
• Interagency collaboration
• Improved integration of care in not just treatment, but in administrative buy-in
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Questions?
SAMHSA-HRSA
INNOVATION COMMUNITY
FINAL PRESENTATION
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Innovation Project Process
Review data
Identify target population
Identify intervention
Develop goals
Staff training
Implementation
Evaluation
Replication
Diabetes and the SMI population
2200 (16%) SMI Integrated Members diagnosed with diabetes• Total cost of ~52 million/year (23%)
• 2500 ED visits/1000 members
• 450 hospital admissions/1000 members
• 100 admissions for diabetes (19%)
• 16 readmissions for diabetes (16%)
Implement PHQ-9 screening during hospital discharge follow up with Members admitted due to diabetes
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OutcomesMetric Q2 2017 Goal
% Members who saw PCP in last 12 months
79.11% ≥90%
Diabetes ED Utilization (/ 1,000 member months)
35.75 32.12 (10%↓)
Diabetes Admits(/1,000 member months)
4.35 3.91 (10%↓)
Diabetes Readmits(/1,000 member months)
16.00% 14.4% (10%↓)
Metric (HEDIS) June 2017 MPS
A1c Testing 65% 77%
A1c Poor Control 89% 43%
Diabetic Eye Exam 34% 49%
Benefits and Barriers
Benefits
• Implementation took place during overall restructure
• Can replicate in other populations
• Low cost solution to a high cost problem
Barriers
• Claims-based data
• Lack of clinical data
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What’s Next?
Explore alternate data sources
• HIE
• Pharmacy
• Labs
Replicate in larger population
Identify depression disparities
Questions
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Diabetes and Depression: An organization’s
attempt to implement an integrated care program
5x5 Presentation
J.C. Blair Memorial Hospital
Shelly D. Rivello, LCSW
Our goals and work plan
• Improved disease management practices (patients, provider, org.)
• Identification of patients/stratification; Review of current interventions and collaboration efforts
• Utilization of available resources
• Referral practices, psychoeducational material, clinical trainings
• Development of additional resources
• Identification of service gaps to fulfill patient and provider needs
• Positively contribute to population health initiatives
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We learned a few things …
• Opportunity to “step back” and look at the program to see what we have,
what we are missing, what we need, and where to go
• Increased awareness of need for specific and targeted efforts
• Recognition of the amount of time and resources needed to appropriately
develop program components
• Emphasis on my role as department leader and collaboration with other
department leaders to achieve goals
Project Outcomes
• Recognition of the amount of purposeful time, effort, and resources
needed for strategic planning and program growth
• Coordination with the Diabetes Self-Management Program; however much
of the need is with diabetic patients (not pre-diabetic)
• Partnership with Directors of Population Health and Integrated Care (new)
• Participation was not as impactful as initially anticipated … JCB limitations
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Next steps
• Continue to be an advocate for my department/needs, program growth;
leverage integrated care strategies
• Coordinate with departments with similar initiatives
• Investigate the financial component of services (sustainability)
• Continue to emphasize integrated care efforts as critical to patient care
• Recognize limitations while pushing the limits!
Project Impact
• This program provided an opportunity to realize the current level of work
conducted, while identifying service gaps
• Made us question the strategy to address the needs (patient/provider)
• Need to define “integrated care” and scope of practice (who?, why?)
• Supported the need for additional exploration regarding diabetes
management and depression management – separately and combined!
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Questions?
MHMR TARRANT
Brian Villegas, DrPH
Chalee Rivers, RN
Megan Wilcox, MSW
Michael Cockerell
SAMHSA-HRSA Innovation Community
August 22, 2017
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GOAL
Implement diabetes and
depression education groups in
order to manage the co-occurring
diagnosis among individuals
receiving integrated health care
services
Implement screening
procedures to identify
individuals with HbA1c>6.5 and
PHQ-9>4
APRN, who is a diabetes
educator, will educate
individuals with both diabetes
and depression on how to
manage their conditions
Goal Work Plan Steps
LESSONS LEARNED
Important to be Flexible and Adaptable
Primary care partnership funded through 1115 Medicaid
Transformation Waiver
New reporting requirements=new work plan
Data Tracking
EHR is still in development
HbA1c Labs at Homeless Services Clinic
Culture Change Takes Time
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RESULTS OF PROJECT
43 individuals in target group
Will monitor PHQ-9 scores every visit and HbA1c values every
6 months to determine effects of the intervention
Total Screened Average ScoreTotal Outside
Normal Range
Total with both
Diabetes and
Depression
PHQ-9 626 12.67 519 (83%)43
HbA1c 151 7.52 72 (48%)
FUTURE ACTIONS
Identify champions within the clinic who are passionate about
health education and are motivated to make a difference
among the population.
Meet prior to health education office visits to identify barriers
and develop action plans.
Find resources that would increase engagement of individuals
in the target group.
Establish a permanent diabetes and depression group on site
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PATIENT & ORGANIZATIONAL IMPACT
MHMR Tarrant is certified as a Texas Certified Community
Behavioral Health Center (CCBHC)
Implementing many new screening procedures across the agency
including the PHQ-9
Innovation community gave us a head start on the agency/clinic
culture change
Emphasis on the whole health of the person, not just mental health
diagnoses
Individuals have increased knowledge of their diagnoses and
how to manage them in tandem
Questions?
8/23/2017
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Let’s Discuss!
Please type your
questions/discussion points in the
chat box!
Report Out
August 23
3 – 4:30 p.m. ET
5 x 5 presentations
Learn how Innovations Community participants are:✓ Progressing toward goals
✓ Sustaining momentum, improving interventions, and garnering
positive gains
✓ Establishing best practice models across the organization
8/23/2017
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Questions?
Thank you for joining us today and
for being a part of our innovation
community. Please take a moment
to provide your feedback by
completing the survey at the end of
today’s webinar.
If you have additional questions/comments, please send them to:
Joe Parks – [email protected]
Deann Jepson – [email protected]
Madhana Pandian – [email protected]