Care IntegrationA Case Study at WVCH

By Ruth Rogers BaumanChairperson, WVCH

CEO, ATRIO Health Plans

Who is WVCH

• ATRIO Health Plans• Capitol Dental Care• Mid Valley Behavoral Network• WVP Health Authority• Northwest Human Services, Inc• Polk County• Salem Clinic, PC

• Salem Health/Salem Hospital• Santiam Memorial Hospital• Silverton Health• West Valley Hospital• Yakima Valley Farm Workers

Clinic

What is Integration

• Is it integration of contracts?

• Is it integration of OHP contractors?

Dental PhysicalBehavioral

What is Integration

• Is it integration of care?Pr

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Non traditional

Conventional Wisdom

• Conventional wisdom says:• Mental Health needs to be integrated into primary care because so many high

utilizers and chronically ill also have mental health issues• You have to have patient centered homes• Non traditional workers can help patients navigate the health system at a

lower cost and with a closer bond • Nurse Case Managers are essential to coordinating primary care, specialty

care and transitions of care

The WVCH ExperienceConventional Wisdom

Mental Health needs to be integrated into primary care because so many high utilizers and chronically ill also have mental health issues

Long history of WVP and BCN working closely togetherX Some clinics are beginning to add mental health resources as part of their PCPCH but warm hand offs are not the norm most of the time

You have to have patient centered homes Large clinics and hospital systems are moving toward level 3, almost all PCP’s are level 1, and WVP is

moving toward level 3 for the balance of the networkNon traditional workers can help patients navigate the health system at a lower cost and

with a closer bond Hired navigators last summer who had a huge impact on high utilizers of ED

Nurse Case Managers are essential to coordinating primary care, specialty care and transitions of care

WVP had 12 nurse case managersX we just needed more

WVCH ExperienceSurvey Says!• All we had to do was get more nurse case managers and more mental

health workers and we would have it made• Then we did a survey

• Salem Hospital reported 22 nurse case managers with 4 support staff and 10 MSW’s

• West Valley Hospital had 1 nurse case manager• NW Senior and Disabilty Services reported 40 case managers, 2 program specialists

and 2 screeners• Salem Clinic reported 1 nurse case manager dedicated to transitions• Salud had 1 nurse case manager• Polk County Mental Health reported 6.5 case managers and 1 drug case manager• WVP had 12 nurse case managers

WVCH Experience

• 110 FTE’s were involved in care coordination• WVCH took a giant step forward by simply identifying resources

already deployed• We learned that even among case managers, we needed a way to

coordinate the coordinators!• Members of the clinical advisory committee gained a deeper

understanding of what each organization was doing and a greater realization of where overlaps, gaps and missed opportunities lie

Key barriers

• Limited Communication• Limited exchange of medical information• Lack of secure systems to exchange information• Lack of alignment of goals• Lack of sharing of care plans• Lack of understanding of care plans• Limited physical contact between team members and with patients

Another Interesting Finding

No one mentioned:• Lack of financial incentive • Lack of shared risk• Lack of time • More people needed

What’s Next

• Clinical Advisory Committee has a number of small projects that are closing the communication gaps• Navigators are being deployed to specific populations at the front end

of care• Common care plans are being deployed for special needs population