care partners annual meeting agendaaims.uw.edu/care-partners/sites/default/files...care partners...

Care Partners Annual Meeting

Agenda Thursday, May 26th, 2016

UC Davis Conference Center

550 Alumni Lane, Davis, CA 95616

Time Topic/Activity Facilitator(s) Location

7:45 Registration

8:00 Welcome & Introductions Ladson Hinton

Laura Rath Jürgen Unützer

8:30 Site Introductions and Presentations Rita Haverkamp

9:45 BREAK

10:00 Caseload Statistics Report and Treatment Adjustment

o Registry demo

Jürgen Unützer

10:45 Overcoming Challenges & Moving Forward Small Group Discussions

o Using the registry

o PHQ-9

Rita Haverkamp

12:00 LUNCH

1:00 Focus Groups UC Davis

AIMS Center

2:15 BREAK

2:30 Overcoming Challenges & Moving Forward (Cont’d)

o Collaboration between primary care and CBO/family

Rita Haverkamp

3:15 Psychiatric Consultant Presentations Lori Raney

4:15 Goal Sharing

o Big Ideas Worksheet

Rita Haverkamp

4:50 Feedback

5:00 Adjourn

First Name Last Name Organization Care Partners Role

Rita Haverkamp AIMS Center Care Manager Coach

Theresa Hoeft AIMS Center Investigator

Lori Raney AIMS Center Psychiatric Consultant Coach

Jürgen Unützer AIMS Center Investigator

Heather Wilcox AIMS Center Project Assistant

Jasmine Lacsamana Archstone Foundation Program Associate

Laura Rath Archstone Foundation Senior Program Officer

Stuart Henderson UC Davis Evaluator

Erika Rivas UC Davis Evaluator

Ladson Hinton UC Davis/VA McClellan Outpatient Clinic Investigator

Thuc‐Nhi Nguyen UC Davis/VA McClellan Outpatient Clinic Project Lead

Angela Araneta VA McClellan Outpatient Clinic Care Manager

Brian Dahmen VA McClellan Outpatient Clinic Project Lead

Jennifer Fallman VA McClellan Outpatient Clinic Care Manager

Chad Murdock VA McClellan Outpatient Clinic Psychiatric Consultant

William Kearney VA Fairfield Outpatient Clinic Psychiatric Consultant

Irma Abaunza El Sol Neighborhood Educational Center Care Manager

Monica Fuentes El Sol Neighborhood Educational Center Care Manager

Amelia Zepeda El Sol Neighborhood Educational Center Project Lead

Brenda Boyle SAC Health System Psychiatric Consultant

Adriana Gomez SAC Health System Care Manager

Myra Buby Family Health Centers of San Diego Project Lead

Jennifer Sagun Family Health Centers of San Diego Care Manager

Joe Sepulveda Family Health Centers of San Diego Psychiatric Consultant

Dennis Dearie Serving Seniors Care Manager

Parwin Tahir Serving Seniors Care Manager

Cami Allard Institute on Aging Care Manager

Clare Farrington Institute on Aging Project Coordinator

David Shoup Institute on Aging Care Manager

Carolyn Stead Institute on Aging Project Lead

Marisa Guardado UCSF Housecalls and Center for Geriatric Care Program Care Manager

Alexis Bradley LifeLong Medical Care Care Manager

Steven Hardy LifeLong Medical Care Interim Project Lead

Jesse Merjil LifeLong Medical Care Care Manager

Megan O'Brien LifeLong Medical Care Psychiatric Consultant

Eva Lumas St. Mary's Center Care Manager

Karla Salazar St. Mary's Center Project Lead & Care Manager

Diane Camurat Sonoma County Human Services Dept. Care Manager

Jenay Cottrell Sonoma County Human Services Dept. Project Lead

Gary Fontenot Sonoma County Human Services Dept. Organizational Liaison and Oversight

Anne Percival Sonoma County Human Services Dept. Care Manager Supervisor

Suzanne Cochrane Petaluma Health Center Project Lead

Philippe Edouard Petaluma Health Center PCP Champion

Todd Finnemore Petaluma Health Center Organizational Liaison and Oversight

Vicki Rivera Petaluma Health Center Care Manager

Olga Robles Petaluma Health Center MH/BH Team Manager

Camilo ZaksUSC Dept. of Family Medicine/USC Family Medicine

Residency ProgramProject Lead

Jose Luevano Eisner Pediatric & Family Medical Center Care Manager

Yadira Ramirez‐Flores Eisner Pediatric & Family Medical Center Care Manager

Adriana Cardenas St. Barnabas Senior Services Care Manager

Gordon Gibb St. Barnabas Senior Services Organizational Liaison and Oversight

John Kotick St. Barnabas Senior Services Project Lead

Care Partners Annual Meeting Attendees ‐ May 26, 2016

Morning Session

Care Partners Annual Meeting 2016 Slide Handout for AM Session

5/26/2016

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Care Partners Annual Meeting 2016

Depression in Late‐Life Initiative

May 26,2016

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Introductions and Overcoming Challenges

Facilitated by Rita Haverkamp, MSN, PMHCNS‐BC, CNS

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Presentation Order

• IOA/UCSF

• PHC/Sonoma County HSD

• USC‐Eisner/SBSS

• FHCSD/Serving Seniors

• VA McClellan

• SACHS/El Sol

• LifeLong/St. Mary’s Center

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Institute on Aging and UCSF Geriatrics

Overcoming Challenges

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Partnership

With UCSF’s primary care providers and IOA’s mental health clinicians having extensive experience in providing home‐based services, this collaboration is an innovative model for serving isolated, homebound older adults struggling with depression.

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Challenge

• One of our greatest challenges was communication across agencies. We needed to create a system in which we could share confidential information between the Institute on Aging and the UCSF Geriatric Care Clinic and UCSF Housecalls program.

• One solution we found to be helpful was to gain read‐only access to their mental health record.

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Challenge working across organizations

• Read‐only access of UCSF’s medical record allowed us to see lists of medications, check dates of most‐recent PCP appointments, and review if Psychiatric Consultation Notes were implemented.

• Our psychiatric consultant is a member of UCSF and is able to enter recommendations directly into UCSF’s EMR.

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Challenges/Problem Solving contd.

• Other strategies for communication included:

– Scheduling PCPs to attend Psychiatric Case Consultation at regular intervals

– Developing a contact sheet with email, phone and pagers for team members

– Solidifying emergency protocols across clinics

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Sonoma County HSD, Adult & Aging Division and Petaluma Health Center


Elder Depression Care Team (Collaborative Care Team)


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Partnership

Community‐Based Organization:

Sonoma County Human Services Department, Adult and Aging Division

Primary Care Clinic:

Petaluma Health Center

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Program Goal

• Home Visiting Care Coordinator embedded into the clinic‐based team at PHC – Our multi‐disciplinary team treats older adults through:

• Clinic:– Primary care and

– Mental health

• In‐Home– Care management

– Creating an optimal opportunity for patients to succeed in their depression management

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Innovation:

• Obtaining access to eClinicalWorks (electronic medical record) for Adult & Aging’s Home Visiting Care Coordinator


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Challenges to Working Across Organizations

Challenges: 1. Home Visiting Care Coordinator not a PHC employee

2. No valid credentialing process for this form of access

3. Multiple bureaucracies with hermetically sealed EHR systems

4. County Services and a Non‐Profit organization with separate, proscribed policies and procedures

5. Valid, important HIPAA and liability concerns

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First steps

• Developed an understanding of what was best for the program vs. beliefs about what was possible

– Bureaucratic PnPs and cultural work flow stopped us (briefly)

• Initiated team collaboration through regular meetings to discuss start up challenges

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Solutions to Integrating Across Organizations Solutions: 1. Brainstorming and innovation

2. Senior management conversations to open dialogue

3. CMIO leadership project review and strategy

4. CMIO to county technician = conversation and innovation

5. Prepared a HIPAA Business Associate Agreement • SCCP: one of several PHC‐HSD (A&A) partnerships

6. County granted access via PHC laptop

7. Provided PHC laptop

8. Provided eClinicalWorks (EMR) training

9. Critical pieces: support, communication, flexibility, commitment and time


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Summary

• Clear goals

• Collaborative spirit

• Team meetings

• In‐person conversations

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Thanks!

• Looking forward to collaborating and brainstorming together

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USC‐Eisner Family Medicine Center at California Hospital and St. Barnabas Senior Services (SBSS)


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Partnership

• USC‐Eisner is working collaboratively with SBSS to help study participants’ access opportunities for socialization, while addressing patients’ depression.

• Patients receive both physical health and mental health services at USC‐Eisner and have access to social activities and patient/caregiver education through SBSS.

• PCPs, therapist, and care managers meet weekly to provide feedback, recommendations, and updates.

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Challenge and Solution

• Challenge: Participants at our clinic were not attending the Patient and Caregiver training sessions at SBSS due to transportation issues to the SBSS site.

• Solution: SBSS began to hold the classes at Eisner Pediatric and Family Center (1 block from the USC‐Eisner site) and attendance rose.

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Family Health Centers of San Diego (FHCSD) and Serving Seniors


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Partnership

• By partnering to improve primary and mental healthcare for the targeted population, FHCSD and Serving Seniors will create a cross‐organizational team that will not only provide medical home engagement and increase diagnosis and appropriate treatment of depression for this population, but also address depressed seniors’ material need insecurities and human need for engagement.

• Material need insecurities are a leading deterrent to an individual’s capability and desire to seek and adhere to ANY kind of primary or mental healthcare treatment – this partnership’s ability to provide this care while significantly reducing material need insecurities is its strength and its heart.

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Challenge

• Patient recruitment has been challenging in both organizations.

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• Engaged staff at both organizations in assessing opportunities to engage in patient recruitment and provide feedback.

• Implemented various suggestions, including:– Distribute PHQ‐9 at all sites and at the Homeless Prevention Program

– FHCSD Care Manager presenting the program at Serving Seniors weekly

– Flyers/announcements distributed at all sites and during all activities

– Established number goal at FHCSD by posting a “patient meter” poster

– Encouraged staff (e.g., Patient Service Representatives and MAs) to distribute PHQ‐9 at time of check‐in; MAs are entering scores in the EHR

– Care Manager providing a highlighted daily list of patients 65+ to the Patient Service Representatives and MAs

– Care Manager is constantly at check‐in area to advertise the program

– Care Manager communicates with PCPs and all involved staff about completed PHQ‐9s, potential new patients, and warm handoffs

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VA McClellan Outpatient Clinic


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Partnership/ Innovation

• We are including family members and/or friends/caregivers to support veterans with depression treatment within the integrated care model

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Challenges

1) Keeping the focus on the veteran and not engaging in couples/family therapy

2) Comorbid substance use and/or PTSD

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Solutions

1) Keeping the focus on the veteran and not engaging in couples/family therapy

• Explaining model well from outset and setting solid structure and purpose of visits

• Acknowledging past issues without going into great detail

• Problem‐solving regarding getting support for partner

• Promoting self care for both vet and partner

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Solutions

2) Comorbid substance use and/or PTSD

• Motivational Interviewing

• Changing session structure to spend more time individually with vet and bringing spouse/family in intermittently or just for a small portion of session

• Highlighting the association between substance use and depression

• Attempting to help vet and family strengthen quality time together and reconnect

• Psychoeducation for vet and family

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El Sol Neighborhood Educational Center and SAC Health System


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Partnership

El Sol and SAC Health System (SACHS) commit to focus on improving care quality and coordination of care among older adults from various racial and ethnic backgrounds in our community with, or at risk for, depression through Collaborative Care by comprehensive community‐based, family‐focused, and patient‐centered outreach and education.

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Challenge

• Giving access to the Community Health Workers (CHWs) at SACHS was a challenge due to clinic protocols.

• Patient information is all confidential and CHWs could not access it unless the patient signed a release of information form.

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• Action (in process): Providing the CHWs with access to the Community Resource Center within the clinic.

• CRC personnel will meet and screen potential clients during their medical appointment and complete a follow‐up visit with a CHW at the CRC after their appointment.– During screening, CRC personnel will express to patient that they will check in with them at the end of their appointment

– CRC personnel will notify Medical Assistants of the need for a follow‐up so patients are not missed before they go home.

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LifeLong Medical Care and St. Mary’s Center


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Partnership

• LifeLong and St. Mary’s partner to offer services for patients who receive their primary care at LifeLong Medical Care Over 60.

• LifeLong Over 60 services: – Personalized care that allows for engagement in therapy – The option to take antidepressant medications– Biweekly check‐in calls from the CHW/Care Manager – Ability to participate in wellness activities as well as walking and support

groups – Ability to request other social service and mental health services.

• St. Mary's Center services:– Additional community engagement services toward their care such as full

access to the community center – Ability to sit and talk with other members of the community over coffee and

pastries – Access to lunch meals and food distribution services– Ability to attend cultural, seasonal, and holiday events as well as creative

arts events.

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Challenge

• Getting LifeLong Over 60 patients to agree to receiving services from St. Mary’s Center– Many patients seem unenthused about traveling to and

engaging in services at St. Mary’s Center because for many it is an unfamiliar place to them

• Overcoming the challenge:– Offering patients the support of a companion (such as our

CHW) to travel with them to SMC for a personalized visit/tour– The option to only receive reassurance/courtesy calls from

SMC staff to ensure that their care is going well for them– The option to decline attending SMC immediately upon

enrolling into the program, but to consider possibly attending or agreeing to calls with SMC at a later date

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BREAKReconvene at 10:00 A.M.

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Caseload Statistics Report and Registry Demo

Facilitated by Jürgen Unützer, MD, MPH, MA

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Care Partners CMTS: https://cmts.uw.edu/CPCMTS.woa

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Overcoming Challenges and Moving ForwardSmall Group Discussions


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Use of the Registry

• How will this change your current use of the registry?

• If you do this already, how does it improve care?

• Will you need to find time or change your schedule to make this happen?

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PHQ‐9

• What ways have you used the PHQ‐9 to drive care?

• How has it helped drive care?

• What kind of difficulties have you had in doing the PHQ‐9?

• What adaptations have you made?

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LUNCHReconvene at 1:00 P.M. in your designated focus group room (see the backside of your nametag)

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Afternoon Session

Care Partners Annual Meeting 2016 Slide Handout for PM Session

5/26/2016

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Overcoming Challenges and Moving Forward (Continued)Small Group Discussions


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Collaboration between Primary Care and CBO/Family

• What has made it easy?

• What has been more challenging than expected?

• How do you have the patient involved in both systems? (For sites working with a CBO)

• What more could you do?

• Did others have ideas this morning that you could implement?

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Psychiatric Consultant Discussion

Facilitated by Lori Raney, MD

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We asked your psychiatric consultants to answer these questions:

1. What are your current interactions with your Collaborative Care teams?

2. What has your experience been of doing the case review?

3. What other significant issues have you had to address as a psychiatric consultant?

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Presentation Order

• FHCSD/Serving Seniors

• LifeLong/St. Mary’s Center

• SACHS/El Sol

• VA McClellan

• IOA/UCSF

• USC‐Eisner/SBSS

• PHC/Sonoma County HSD

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Family Health Centers of San Diego (FHCSD) and Serving Seniors


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Introduction

• Psychiatric Consultant: Joe Anthony Sepulveda, MD, ABPN

• Family Health Centers of San Diego and Serving Seniors

– Margarita Velosa (FHCSD)

– Parwin Tahir (Serving Seniors)

– Dennis Dearie (Serving Seniors)

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What are your current interactions with your Collaborative Care team?• Due to geographical limitations, our care team meets solely via telephone and electronic communication.

• Communication with our PCP counterparts:– CMTS– Internal EHR and EHR messaging platform– Face to face between PCP and care manager and/or via telephone with psychiatrist

• Teaching/Questions/Improvement:– My team is encouraged to:

• Discuss challenging patients. • Ask questions about diagnosis, treatment, etc.• Collaboratively discuss areas of concern/improvement.

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What has your experience been of doing the case review?• Overall a very positive collaborative experience.

• Interesting/unexpected events:

– Patient discussed, recommendations made but patient went to SNF.

• Communicated with SNF to convey recommendations to new care team.

– Logistics of enrolling patients in the setting of having an established outside PCP.

– Working with PCPs to streamline screening and referral to the program.

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Other significant issues you have had to address as a psychiatric consultant

• Efficiency:

– Discussing case and transcribing clinical information into two separate health record systems.

• Clinical Comfort:

– In assessing and recommending interventions without seeing the patient.

– Relying on members of the clinical team to be your eyes and ears in obtaining pertinent history.

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Additional insights gleaned throughout the day

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LifeLong Medical Care and St. Mary’s Center


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Introduction

• Psychiatric Consultant: Megan O’Brien

• LifeLong Medical Care and St. Mary’s Senior Center

– Karla Salazar (St. Mary’s)

– Sr. Eva Lumas (St. Mary’s)

– Jesse Merjil (LifeLong)

– Alexis Bradley (LifeLong)

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What are your current interactions with your Collaborative Care team?• Communication with Care Managers

– We meet on a weekly basis to discuss patient cases and consult on patients that are currently enrolled as well as patients that have screened positive but may be ineligible due to other circumstances.

• Communication with PCP– PCP communication generally happens during our weekly Archstone

team meetings. We use this time to address any concerns between myself and the PCP. If we have questions or concerns that need to be addressed in between team meetings we communicate through our EHR system NextGen to relay important or immediate information.

• Staff interactions– I frequently interact with all staff involved in the grant. Our weekly

meeting ensures that staff are in frequent communication and both sites are well informed of my role as the consultant and understand that they can approach me with concerns or questions about patients throughout the grant process.

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What has your experience been of doing the case review?• We have not had very many issues come up during weekly case reviews. Many of our consultations take a generous amount of time, but we generally are able to determine whether or not a patient is eligible for the program or if a necessary change needs to made to their care during this time.

• During case reviews we have a computer available to view patient charts on our EHR system and access current patient medications, previous and current diagnoses, and PCP notes within the patient charts.

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• It is unclear whether or not patients who already receive primary care in the clinic and are already seeing me for depression treatment can enroll in the study.

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El Sol Neighborhood Educational Center and SAC Health System


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Introduction

• Psychiatric Consultant: Brenda Boyle, PMHNP‐BC, MSN, RN

• SAC Health System & El Sol Neighborhood Educational Center

– Adriana Gomez (SACHS)

– Irma Abaunza (El Sol)

– Monica Fuentes (El Sol)

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What are your current interactions with your Collaborative Care team?• Weekly check‐in with Clinic Care Manager and phone conferences with CBO Care Managers to discuss our clients’ progress, response to the intervention and suggestions for treatment changes (where needed)

• Use the clinic’s EHR system to notify PCPs of updates for enrolled clients– # of enrolled clients is low, but other methods of communication will be explored as enrollment grows

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What has your experience been of doing the case review?

• Problem: Gathering a “wider perspective” of each enrolled client

– Some discomfort with providing feedback or assessing client’s mental health with limited information on their overall well‐being

• Suggestion: Providing a “snapshot” of the client’s life outside of the clinic during consults (i.e., financial status, access to food, support network)

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• Brief review of the social needs that each client presents will allow for a better understanding on their daily struggles and how this impacts their emotional well‐being

– Willingness to actively participate in intervention

– Assess their ability to adhere to current medication regimen, or changes to it

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VA McClellan Outpatient Clinic


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Introduction

• Psychiatric Consultant: Chad L Murdock, MD

• McClellan VA Clinic (Sacramento)

– Angela Araneta

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What are your current interactions with your Collaborative Care team?• Care Manager

– Weekly scheduled meeting with care manager plus brief additional 1 on 1 coordination as needed

• PCP

– Bimonthly scheduled meeting with PCP group includes 5‐10 min PCMHI topic discussion as well as any depression study discussion/coordination

– 1 on 1 coordination as needed: instant message, face to face, co‐signing progress notes

– E‐consults26

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• Finding missed orders by PCP to start or increase antidepressants after plan to do so had been agreed on (brief face to face or instant message with PCP solves this)

• Learning to only make just one medication recommendation on an E‐consult (I indicated drug A or B, PCP ordered both)

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• VA systems issues

– New patient clinics

– New electronic record note titles

– New ways to get work credit

• Primary Care Provider issues

– Acceptance of psychiatric consultant

– Acceptance of integrated care model

– Acceptance of E‐consults

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Institute on Aging and UCSF Geriatrics


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Introduction

• Psychiatric Consultant: Alexis Armenakis, MD

• UCSF and Institute on Aging

– Cami Allard (IOA)

– David Shoup (IOA)

– Marisa Guardado (UCSF)

• Presented by Carolyn Stead (Project Lead, IOA)

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What are your current interactions with your Collaborative Care team?

• Weekly phone meetings with the care managers and PCPs

• Each CMTS note is copied into the UCSF medical record as “documentation note” and routed to PCP

• Interact both with care managers from the primary care clinic and community‐based organization

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What has your experience been of doing the case review?• No major issues – CM’s strong in holding patient care

• Limited time per case – hard to know if I’m pitching information at the right level for providers or addressing most pressing issues

• Coaching/teaching CM’s to present in an organized way to optimize time

• Some need to discuss process around time allocation per patient: breadth vs. depth, at what level should I be thinking about patients, which pts need more in‐depth discussion

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What has your experience been of doing the case review? (Continued)• Interdisciplinary discussions most high yield• Role as psych consultant: Balancing being “content expert” and providing helpful information with making space for interdisciplinary input and expertise of CM’s and PCP who are seeing the patient

• Weighing in on medications, psychosocial interventions, and overall interpersonal dynamics in the cases

• Providing education to the team has been very enjoyable

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USC‐Eisner Family Medicine Center at California Hospital and St. Barnabas Senior Services (SBSS)


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Introduction

• Psychiatric Consultant: Welcoming Dr. Dave Baron, Interim Chair, Department of Psychiatry, USC Keck School of Medicine

• USC‐Eisner‐SBSS Combination CBO/Caregiver “BALLAD” Project– Eveline Zamora (Eisner)

– Ana Rosas (Eisner)

– Jose Luevano (Eisner)

– Yadira Ramirez‐Flores (Eisner)

– Adriana Cardenas (interim for Maria De Leon) (SBSS)

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Disclaimer

• The USC‐Eisner‐SBSS project had been working without a Psychiatric Consultant until May 2016.

• Early on we had a commitment from a community Psychiatrist identified via a local Geriatric healthcare agency, however he was never able to participate in Case Reviews due to incomplete paperwork.

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What has it been like doing this work without a Psychiatric Consultant?

• Our workflow has continued as initially outlined, including weekly Case Reviews led by the PCP champion.

• Mostly we have seen success, however there have been some instances where the team was challenged by “hitting the ceiling” of knowledge and comfort with psychoactive medications.

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What challenges have you faced?

• Three patients had persistently elevated PHQ‐9 scores despite PST, SSRI, connection to CBO and Care Giver training.

• On further review, 2 of the patients were identified by the LCSW CM as not taking their SSRI as directed. LCSWs are now working to encourage medication compliance.

• The last case did have a persistently elevated PHQ‐9, and the team would have really liked to have been able to discuss with a PC alternative options for treatment with psychoactive meds.

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Case where we really needed a PC

• Ms. AG has had severe MDD and GAD.

• Her PHQ‐9 scores are consistently above 18.

• She has had therapy on and off for years.

• She has been on Lexapro of up to 20mg for several years in the past and currently on Cymbalta 120mg/day since 2014 to help with her fibromyalgia.

• She was dx with MDD with psychotic features by a psychiatrist from 2009‐2011 and was started on Seroquel at bedtime in 2013 which she continues to take.

• Her last PHQ‐9 score on 4/22/16 was 23.41

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Sonoma County HSD, Adult & Aging Division and Petaluma Health Center


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Introduction

• Psychiatric Consultant: Ken Weinstock, MD

• Petaluma Health Center and Sonoma County HSD Adult and Aging Division

– Vicki Rivera (PHC)

– Diane Camurat (Sonoma Co.)

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What are your current interactions with your Collaborative Care team?

• Weekly video telephony meetings

• Shared electronic medical records messaging and consultations

• All interactions are with PHC clinic‐based CC team Care Managers and patients’ PCPs

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• Weekly case review time is protected and well‐organized into work flow.

• Care Managers are prepared to make best use of limited time.

• Clients to be reviewed and consultation questions are organized prior to meeting.

• Broader discussions of mental health care and therapy interventions.

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Other significant issues you have had to address as a psychiatric consultant• Two distinct medical records systems. All client medical records are available for review in real time (medications, visits, referrals etc.)

• Balancing brief interval per consultation with useful interchange of information and ideas.

• Creating a shared structure for case presentations.

• When to schedule direct psychiatric consultations with enrolled patients.

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GOAL SHARING

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FEEDBACK

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ADJOURN

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